Nursing Care Plan

Nursing Diagnosis
Ineffective Airway Clearance r/t tracheobronchial obstruction

Long Term Goal:

Patient will maintain a patent airway

Short Term Goals / Outcomes:

Patients lungs sounds will be clear to auscultate
Patient will be free of dyspnea
Patient will demonstrate correct coughing and deep breathing techniques

Intervention

Rationale

Evaluation

Assess airway for patency Maintaining an airway is always top priority especially in Patient is able to state their name without
by asking the patient to
patients who may have experienced trauma to the airway. difficulty.
state his name.
If a patient can articulate an answer, their airway is patent.

Inspect the mouth, neck

Foreign materials or blood in the mouth, hematoma of the No foreign objects, blood in mouth noted.
and position of trachea for neck or tracheal deviation can all mean airway obstruction. Neck is free of hematoma. Trachea is
potential obstruction.
midline.

Auscultate lungs for

presence of normal or
adventitious lung sounds.

Decreased or absent sounds may indicate the presence of a Patients lungs sounds are clear to
mucous plug or airway obstruction. Wheezing indicates
auscultation throughout all lobes.
airway resistance. Stridor indicates emergent airway

obstruction.

Assess respiratory quality, Flaring of the nostrils, dyspnea, use of accessory muscles, Patient is free of signs of distress.
rate, depth, effort and
tachypnea and /or apnea are all signs of severe distress that
pattern.
require immediate intervention.

Assess for mental status

changes.

Increasing lethargy, confusion, restlessness and / or

irritability can be early signs of cerebral hypoxia.

Patient is awake, alert and oriented X3.

Assess changes in vital

signs.

Tachycardia and hypertension occur with increased work

of breathing.

Patient is normotensive with heart rate 60

100 bpm.

Monitor arterial blood

gases (ABGs).

Increasing PaCO2 and decreasing PaO2 are signs of

respiratory failure.

ABGs show PaCO2 between 35-45 and

PaO2 between 80 100.

Administer supplemental
oxygen.

Early supplemental oxygen is essential in all trauma

Patient is receiving oxygen. SaO2 via pulse
patients since early mortality is associated with inadequate oximetry is 90 100%.
delivery of oxygenated blood to the brain and vital organs.

Position Patient with head Promotes better lung expansion and improved gas
of bed 45 degrees (if
exchange.

Patients rate and pattern are of normal

tolerated).

depth and rate at 45 degree angle.

Assist Patient with

coughing and deep
breathing techniques
(positioning, incentive
spirometry, frequent
position changes).

Assist patient to improve lung expansion, the productivity

of the cough and mobilize secretions.

Patient is able to cough and deep breathe

effectively.

Prepare for placement of

endotracheal or surgical
airway (i.e.
cricothyroidectomy,
tracheostomy).

If a patient is unable to maintain an adequate airway, an

artificial airway will be required to promote oxygenation
and ventilation; and prevent aspiration.

Artificial airway is placed and maintained

without complications.

Confirm placement of the

artificial airway.

Complications such as esophageal and right main stem

intubations can occur during insertion. Artificial airway
placement should be confirmed by CO2 detector, equal
bilateral breath sounds and a chest x-ray.

CO2 detector changes color, bilateral breath

sounds are audible equally and artificial
airway is at the tip of the carina on x-ray.

If maxillofacial trauma is
present:

The patient with maxillofacial trauma is usually more

comfortable sitting up. Any time there is trauma to the
maxillofacial area there is the possibility of a
compromised airway.

Patient exhibits normal respiratory rate and

depth in sitting position. Patient is free of
wheezing, stridor and facial edema.

1.

position the patient

for optimal airway

clearance and
constant
assessment of
airway patency
2.

note the degree of

swelling to the face
and amount of
blood loss

3.

prepare the patient

for definitive
treatment

If neck trauma is present:

1.

assess for potential

hemorrhage and
disruption of the
larynx or trachea

2.

prepare the patient

for CT scan

Noting swelling is important as a baseline for comparison

later.

Hemorrhage or disruption of the larynx and trachea can be Patient is free of signs of hemorrhage or
seen as hoarseness in speech, palpable crepitus, pain with disruption. CT scan reveals no injury to the
swallowing or coughing, or hemoptysis. The neck should larynx.
be also assessed for ecchymosis, abrasions, or loss of
thyroid prominence.
Laryngeal injuries are most definitely diagnosed by CT
scans as soft tissue neck films are not sensitive to these
injuries.

Teach patient correct coughing and Deep breathing techniques.

Weak, shallow breathing and coughing is ineffective in removing secretions.
Patient is able to demonstrate correct coughing and breathing techniques.

Nursing Diagnosis

Long Term Goal

Impaired Gas Exchange r/t altered oxygen supply

Patient will maintain optimal gas

exchange

Short Term Goals / Outcomes:

Patient will maintain normal arterial blood gas (ABGs).
Patient will be awake and alert.
Patient will demonstrate a normal depth, rate and pattern of respirations.

Interventions

Rationale

Evaluation

Assess respirations:
Rapid, shallow breathing and hypoventilation affect gas
quality, rate, pattern, depth exchange by affecting CO2 levels. Flaring of the nostrils,
and breathing effort.
dyspnea, use of accessory muscles, tachypnea and /or apnea
are all signs of severe distress that require immediate
intervention.

Patient is free of signs of distress.

ABGs show PaCO2 between 35-45
Pts respirations are of a normal rate and
depth.

Assess for life-threatening

problems. (i.e. resp arrest,
flail chest, sucking chest
wound).

Absence of ventilation, asymmetric breath sounds, dyspnea

with accessory muscle use, dullness on chest percussion and
gross chest wall instability (i.e. flail chest or sucking chest
wound) all require immediate attention.

Patient exhibits spontaneous breathing, no

dyspnea, use of accessory muscles,
resonance on percussion and no chest wall
abnormalities.

Auscultate lung sounds.

Also assess for the

Absence of lung sounds, JVD and / or tracheal deviation

could signify a Pneumothorax or Hemothorax.

Patients lungs sounds are clear to

presence of jugular vein

distention (JVD) or
tracheal deviation.

auscultate throughout all lobes.

Assess for signs of

hypoxemia.

Tachycardia, restlessness, diaphoresis, headache, lethargy

and confusion are all signs of hypoxemia.

Patient is free of signs of hypoxia.

Monitor vital signs.

Initially with hypoxia and hypercapnia blood pressure (BP), Patient is normotensive with heart rate 60
heart rate and respiratory rate all increase. As the condition 100 bpm and respiratory rate 10-20.
becomes more severe BP may drop, heart rate continues to
be rapid with arrhythmias and respiratory failure may ensue.

Assess for changes in

orientation and behavior.

Restlessness is an early sign of hypoxia. Mentation gets

worse as hypoxia increases due to lack of blood supply to
the brain.

Patient is awake, alert and oriented X3.

Monitor ABGs.

Increasing PaCO2 and decreasing PaO2 are signs of

respiratory failure.

ABGs show PaCO2 between 35-45 and

PaO2 between 80 100.

Place the patient on

continuous pulse
oximetry.

Pulse oximetry is useful in detecting changes in

oxygenation. Oxygen saturation should be maintained at
90% or greater.

SaO2 via pulse oximetry remains at 90

100%.

Assess skin color for

development of cyanosis,
especially circumoral
cyanosis.

Lack of oxygen delivery to the tissues will result in

cyanosis. Cyanosis needs treated immediately as it is a late
development in hypoxia.

Provide supplemental
Early supplemental oxygen is essential in all trauma
oxygen, via 100% O2non- patients since early mortality is associated with inadequate
rebreather mask.
delivery of oxygenated blood to the brain and vital organs.

Patient is free of cyanosis.

Patient is receiving 100% oxygen.

SaO2 via pulse oximetry is 90 100%.

Prepare the patient for

intubation.

Early intubation and mechanical ventilation are necessary to Artificial airway is placed and maintained
maintain adequate oxygenation and ventilation, prior to full without complications.
decompensation of the patient.

Treat the underlying

injuries with appropriate
interventions.

Treatment needs to focus on the underlying problem that

leads to the respiratory failure.

Appropriate injury specific treatment has

been started.

Paradoxical movements accompanied by dyspnea and pain

in the chest wall indicate flail chest. Flail chest is a lifethreatening complication of rib fractures that requires
mechanical ventilation and aggressive pulmonary care.
Pain relief is essential to enhance coughing and deep
breathing.

No paradoxical movements are noted.

Patient reports pain as <3 on 0-10 scale.
Bilateral breath sounds present in all
lobes.

If rib fractures exist:

1.

Assess for
paradoxical chest
movements.

2.

Provide adequate
pain

3.

relief.

Assess breath sounds.

Absence of bilateral breath sounds in the presence of a flail

chest, indicates a pneumo/hemo thorax.

If Pneumothorax or
Hemothorax exist:
1.

obtain chest x-ray

2.

prepare for
insertion of a chest
tube

A chest x-ray confirms the presence of a Pneumothorax

and / or Hemothorax.
A chest tube decreases the thoracic pressure and re-inflates
the lung tissue.

Chest tube is placed and connected to

20cm wall suction with good tidaling and
no air leak or SQ emphysema noted.

A three sided dressing gives the accumulated air a way to

escape, thereby decreasing thoracic pressure and preventing Three-sided dressing maintained. No
If open Pneumothorax
further cardiopulmonary decompensation
exists place a dressing that a tension Pneumothorax. A chest tube must then be
noted in patient.
is taped on three sides for inserted.
temporary management.

Position patient with head Promotes better lung expansion and improved gas
of bed 45 degrees (if
exchange.
tolerated).

Assist patient with

coughing and deep
breathing techniques
(positioning, incentive
spirometry, frequent

Patients rate and pattern are of normal

depth and rate at 45 degree angle.

Promotes alveolar expansion and prevents alveolar collapse. Patient is able to cough and deep breathe
Splinting helps reduce pain and optimizes deep breathing
effectively.
and coughing efforts.

position changes, splinting

of the chest).

Suction patient as needed. Suctioning aides to remove secretions from the airway and
optimizes gas exchange.

Patient suctioned for moderate amount of

thin yellow secretion. Lung sounds clear
after suctioning.

Hyperoxygenate patient
with 100% before and
after suctioning. Keep
suctioning to 10-15
seconds.

Prevents alteration in oxygenation during suctioning.

Patients SaO2 remained >90% during

suctioning.

Pace activities and

provide rest periods to
prevent fatigue.

Even simple activities, such as bathing, can increase oxygen No changes to cardiopulmonary status
consumption and cause fatigue.
noted during activity.
Patients SaO2 remains >90% during
activities.

Nursing Diagnosis
Deficient Fluid Volume r/t active fluid loss due to bleeding

Long Term Goal

Patient will maintain adequate fluid and
electrolyte balance.

Short Term Goals / Outcomes:

Patient will maintain urine output >30cc/hr.
Patient will be normotensive with heart rate 60 -100bpm.
Patient will demonstrate normal skin turgor.

Interventions

Rationale

Evaluation

Palpate pulses: carotid, brachial,

radial, femoral, popliteal and
pedal. Note quality and rate.

If carotid and femoral pulses are palpable, then the

blood pressure is usually at least 60 80 mmHg
systolic. If peripheral pulses are present, the blood
pressure is usually higher than 80 mmHg systolic.
Pulses may be weak and irregular.

All pulses palpable, strong and regular.

Assess skin color and temperature. Cool, pale, diaphoretic skin suggests ineffective
circulation due to hypovolemia.

Skin pink, warm and dry.

Monitor patient for active blood

loss from wounds, tubes, etc.
Control any external bleeding.

Active fluid and/or blood loss adds to Hypovolemic

state and must be accounted for when replacing
fluids.

All external bleeding controlled.

Monitor vital signs. (T,P,R,B/P)

Sinus tachycardia may occur with hypovolemia to

maintain cardiac output. Hypotension is a hallmark
of hypovolemia. Febrile states decrease body fluids

Vital signs within normal limits.

through perspiration and increase respiratory rate.

Monitor blood pressure for

orthostatic changes.

Greater than 10 mmHg drop signifies that circulating No orthostatic changes noted when
volume is reduced by 20%. Greater that 20 30
patient placed from supine to Fowlers
mmHg drop signifies blood volume is decreased by
position.
40%.

Auscultate heart tones and inspect Abnormally flattened jugular veins and distant heart
jugular veins.
tones are signs of ineffective circulation.

S1, S2 audible. No flattening or

distention of jugular vein noted.

Assess mental status.

Loss of consciousness accompanies ineffective

circulating blood volume to the brain.

Awake, alert and oriented X3.

Assess skin turgor over the

sternum or inner thigh; and assess
moisture and condition of mucous
membranes.

Dry mucous membranes and tenting of the skin are

Normal skin turgor. Mucous membranes
signs of hypovolemia. The sternum and inner thigh pink and moist.
should be used for skin turgor due to loss of elasticity
with aging.

Assess color and amount of urine. Concentrated urine and output <30cc for two
consecutive hours indicate insufficient circulating
volume.

Urine clear, yellow. Output at least

30cc/hr.

Monitor serum electrolytes and

urine osmolality.

Elevated hemoglobin, Hematocrit and blood urea

nitrogen (BUN) accompany a fluid deficit. Urine
specific-gravity is also increased.

All lab values within normal ranges.

Monitor hemodynamic pressures:

central venous pressure (CVP),
pulmonary artery pressure (PAP),
pulmonary capillary wedge
pressure (PCWP), if available.

All values decrease with inadequate circulating

volume. Hemodynamic stability is the goal of fluid
replacements. Monitoring of hemodynamic
pressures can guide fluid replacements.

All pressures within normal ranges.

Initiate two large bore intravenous

catheters (IVs) and start
intravenous fluid replacements as
ordered.

14 -16 gauge catheters are preferred in case fluids

need to be given rapidly. Parenteral fluids are
necessary to restore volume. Lactated Ringers is
usually the fluid of choice due to its isotonic
properties and close resemblance to the electrolyte
composition of plasma.

Two large bore IVs started, lactated

ringers infusing as per physician orders
without complications.

Obtain a serum specimen for type

and cross matCh Administer
blood and blood products as
ordered.

Blood and blood products will be necessary for

Type and cross sent. Type specific blood
active blood loss. If there is no time to wait for cross infusing as per physician orders.
matching, Type O blood may be transfused.

During treatment monitor for

signs of fluid overload.

Due to large amounts of fluids administered rapidly,

circulatory overload can occur. Headache, flushed
skin, tachycardia, venous distention, elevated

No signs of overload noted with fluid

replacements.

hemodynamic pressures (CVP, PCWP), increased

blood pressure, dyspnea, crackles, tachypnea and
cough are all signs of overload.

Assist the physician with insertion Provides for more effective fluid replacements and
of a central venous line and
accurate monitoring of hemodynamic picture.
arterial line if indicated.

Central venous line and arterial line

inserted without difficulty.

Nursing Diagnosis
Acute Pain r/t trauma

Long Term Goal

Patient will be free of pain

Short Term Goals / Outcomes:

Patient will report pain less than 3 on 0-10 scale.
Patients vital signs will be within normal limits.

Interventions

Rationale

Evaluation

Assess pain characteristics:

quality (sharp, burning);
severity (0 -10 scale);

A good assessment of pain will help in the treatment and ongoing

management of pain.

Patient reports pain as 3 or

less on 0-10 scale; intermittent

location; onset (gradual,

sudden); duration (how long);
precipitating or relieving
factors.

Monitor vital signs.

and sharp in incision area.

Tachycardia, elevated blood pressure, tachypnea and fever may

accompany pain.

Vital signs within normal

limits.

Assess for non-verbal signs of Some patients may verbally deny pain when it is still present.
pain.
Restlessness, inability to focus, frowning, grimacing and guarding
of the area may be non-verbal signs of acute pain.

No non-verbal signs of pain

noted.

Give analgesics as ordered

Narcotics are indicated for severe pain. Pain medications are
and evaluate the effectiveness. absorbed and metabolized differently in each patient, so their
effectiveness must be assessed after administration.

Analgesics given as ordered.

Patient reports satisfactory
pain relief after
administration.

Assess the patients

expectations of pain relief.

Some patients are content with reduction in pain, others may expect Patient states I want some
complete elimination. This effects the patients perception of the
relief. I know some pain will
effectiveness of treatment.
still exist.

Assess for complications to

analgesics, especially

Excessive sedation and respiratory depression are severe side effects No complications of analgesia
that need reported immediately and may require discontinuation of

respiratory depression.

medication. Urinary retention, nausea/vomiting and constipation

can also occur with narcotic use and need reported and treated.

noted.

Anticipate the need for pain

relief and respond
immediately to complaints of
pain.

The most effective way to deal with pain is to prevent it. Early
intervention can decrease the total amount of analgesic required.
Quick response decreases the patients anxiety regarding having
their needs met and demonstrates caring.

Patient reports pain as soon as

it starts.

Eliminate additional stressors

when possible. Provide rest
periods, sleep and relaxation.

Outside sources of stress, anxiety and lack of sleep all may

exaggerate the patients perception of pain.

Patient appears relaxed, is

sleeping throughout the night.

Institute non-pharmacological Non-pharmacological approaches help distract the patient from the
approached to pain
pain. The goal is to reduce tension and thereby reduce pain.
(detraction, relaxation
exercises, music therapy, etc.).

Patient is relaxing by use of

non-pharmacological
technique of choice.

If patient is on patient
controlled analgesia (PCA):

PCA infusing without

complications. Patient and
family understand purpose
and use of PCA. Patient is
getting adequate pain relief
with current dose.

1.

Dedicate an IV line for

PCA only.

2.

Assess pain relief and

the amount of pain the
patient is requesting.

Drug interaction may occur, if dedicated line is not possible consult

pharmacist before mixing drugs.
If demands for the drug are frequent the basal or lock-out dose may
need to be increased to cover the patients pain.
If demands for the drug are very low, the patient may need further
education of use of the PCA.

3.

Educate patient and

significant others on
correct use of PCA.

If the patient is receiving

epidural analgesia:
1.

Assess for numbness,

tingling in extremities;
and a metallic taste in
the mouth.

2.

Label all tubing clearly.

The patient and significant others must understand that the patient is
the only one who should control the PCA.

These symptoms indicate an allergic response, or improper catheter

placement.
Labeling of tubing is necessary to prevent inadvertent
administration of fluids or drugs in the epidural space.
Catheter migration or improper administration through the catheter
can result in life-threatening complications.

For PCA and epidural

analgesia:
1.

2.

Keep Narcan readily

available.

All tubing labeled. No signs

of allergic reaction or catheter
migration noted.

Narcan on unit if needed.

Sign placed in room for safety.
In event of respiratory depression reversal agent must be available.
This prevents inadvertent analgesia overdosing.

Place No additional
analgesia sign over
head of bed.

Nursing Diagnosis
Risk For Infection r/t inadequate primary defenses

Long Term Goal

Patient will be free of infection

Short Term Goals / Outcomes:

Patient will maintain normal vital signs.
Patient will demonstrate absence of purulent drainage from wounds, incisions and tubes.

Interventions

Rationale

Evaluation

Assess for presence of risk factors: open

wounds, abrasions; indwelling catheters;
drains; artificial airways; and venous
access devices.

Represent a break in bodys first line of defense.

Patient has midline thoracic

incision, Foley, chest tube and
peripheral IV access.

Monitor white blood count (WBC).

Normal WBC is 4-11 mm3. Rising WBC indicates the

bodys attempt to combat pathogens.

Patients WBC are within the

normal range.

Monitor incisions, injured sites and exit

sites of tubes, drains and catheters for
signs of infection.

Redness, swelling, increased pain, or purulent drainage

is suspicious of infection and should be cultured.

All areas are without signs of

infection.

Monitor temperature and the presence of In the first 24-48 hours fever up to 38 degrees C
sweating and chills.
(100.4F) is related to the stress of surgery. After 48
hours fever above 37.7C (99.8F) suggests infection.
High fever with sweating and chills suggests

Temperature is less than 37.7C.

No sweating or chills present.

septicemia.

Monitor the color of respiratory

secretions.

Yellow or yellow-green sputum indicates a respiratory

infection.

Patient coughs up only thin

clear secretions.

Monitor the appearance of urine.

Cloudy, foul-smelling urine, with sediments indicates a

urinary tract or bladder infection.

Urine is clear yellow with no

sediments.

Maintain strict aseptic technique with all Strict asepsis is necessary to prevent crossdressing changes; tubes, drains and
contamination and nosocomial infections.
catheter care; and venous access devices.

No further infections are noted.

Wash hands and teach others to wash

hands before and after patient care.

Hand washing reduces the risk of transmitting

pathogens from one area of the body to another as well
as from one patient to another.

No further infections are noted.

Encourage fluid intake of 2000ml

3000ml of water per day (unless
contraindicated).

Fluids promote frequent emptying of the bladder,

reducing stasis of urine and risk of urinary tract and
bladder infections.

Patient drinks 2000 -3000 ml of

fluid. No presence of urinary
tract or bladder infections.

Encourage intake of protein and calorie

Optimal nutritional status promotes wound healing.

Wounds are well approximated.

rich foods. Provide enteral feeding in

patients who are NPO.

Encourage coughing and deep breathing. Reduces stasis of pulmonary secretions, reducing the
risk of pneumonia.

Administer and teach the use of

antimicrobial drugs as ordered.

Patient coughs up thin clear

secretions.

All agents are either toxic to the pathogens or retard the WBC within normal limits. No
pathogens growth. Ideally medications should be
further infections noted.
selected based on a culture from the infected area. A
broad-spectrum agent may be started until culture
reports are available.

Nursing Diagnosis
Risk For Ineffective Tissue Perfusion: peripheral, renal, GI, cardiopulmonary, or central r/t
hypovolemia, decreased arterial flow & cerebral edema

Short Term Goals / Outcomes:

Patient will maintain strong peripheral pulses.
Patient will report absence of chest pain.
Patient will be awake, alert and oriented.
Patient will maintain normal arterial blood gases (ABGs).
Patient will maintain normal urine output.

Long Term Goal

Patient will maintain optimal
tissue perfusion to vital organs

Patient will maintain normal bowel sounds.

Interventions

Rationale

Assess each area for signs of

decreased tissue perfusion.

Early detection facilitates prompt, effective treatment.

Evaluation

Signs may be:

Peripheral: weak, absent pulses; edema; numbness, pain, aches; cool
to touch; mottling; prolonged capillary refill
No signs of decreased
Cardiopulmonary: tachycardia, arrhythmias, hypotension,
perfusion noted.
tachypnea, abnormal ABGs, angina
Renal: decreased output, hematuria, elevated BUN/creatinine ratio
GI: decreased or absent bowel sounds; nausea; abdominal pain /
distention
Cerebral: restless, change in mentation seizure activity, papillary
changes and decrease reaction to light

Monitor vital signs for optimal Adequate perfusion to vital organs is essential. A mean arterial
cardiac output.
blood pressure of at least 60 mmHg is essential to maintain
perfusion.

All vital signs within normal

limits.

Administer fluids and blood

products as ordered.

Fluids infusing. Vital signs,

urine output and mentation all
within normal limits.

Aids in maintaining adequate circulating volume to prevent

irreversible ischemic damage.

Anticipate the need for

possible antithrombolytic
therapy.

If an obstruction to the area has developed an embolectomy,

heparinzation, or thrombolytic therapy may be necessary to restore
flow and prevent ischemia

Assess for compartment

syndrome if peripheral
circulation is impaired (pain,
palor, pulselessness, paralysis,
parathesia).

Compartment syndrome develops as the tissue swells and the fascial No signs of compartment
covering over the muscles can not yield to the pressure. Blood flow syndrome noted.
to the extremity is drastically reduced. An emergent fasciotomy
may need to be performed to restore flow.

Administer oxygen as
prescribed. Titrate oxygen
based on continuous pulse
oximetry levels.

Oxygen saturates circulating hemoglobin and increases the

effectiveness of blood that reached the ischemic tissues. Thus
improving tissue perfusion.

Patient receiving oxygen.

Pulse Oximetry 90 100%.

Monitor ABGs, especially for

metabolic acidosis and
hypoxia.

Metabolic acidosis and hypoxia indicate that tissues are not

adequately being perfused.

ABGs within normal limits.

If Patient complains of angina; NTG causes vasodilation, decreases preload and afterload and thus
improves perfusion to the myocardium.
1.

administer nitroglycerin
(NTG) sublingually.

Heparin infusing. PTT within

therapeutic range.

NTG administer. Patient

reports relief of angina.

If cerebral perfusion is
compromised:
1.

Ensure proper
functioning of
intracranial pressure
(ICP) catheter if
present.

2.

Elevate head of bed 30

-45 degrees.

3.

Avoid measures that

may trigger increased
ICP

4.

Administer
anticonvulsants as
needed.

Patient awake and alert with

no change in mentation.
Promotes venous outflow from brain and helps reduce pressure.
No seizures noted.
Straining, coughing, neck or hip flexion and lying supine may
increase ICP and further reduce blood flow.
Reduces the risk of seizures, which may result from cerebral edema
or ischemia.

References: Gulianick, M. and Myers, J. (2003). Nursing Care Plans: Nursing Diagnosis and Interventions. Mosby: St. Louis Taylor, K. Chapter
8. Care of the Patient Following a Traumatic Injury