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YOu are caring for Mary Smith, a 68 year old femal

YOu are caring for Mary Smith, a 68 year old female patient admitted for falling down the stairs in her home During the fall she hit her head, causing a significant head injury. Mary has been lethargic since arriving at the hospital. She is accompanied by her daughter and son who live nearby. Assessment data : HR65, BP 108/62, RR 42, 02 88% on 6 L simple face mask, T 98.8F, Mary is drifting off to sleep frequently . Respiration are labored and irregular, some periods of apnea noted, with occasional de saturation. LSC. Abdomen soft, last BM this morning. Hyperactive bowel sounds UO 75 to 100 mL per hour. 2+ pedal pulses pink, warm, dry extremities. Trace (1+) edema noted. Repositioning q 2 hours , with facial grimacing and spikes in HR and BP during repositions . IV fluids lactated ringers. @50ml/hour Care Planning Assessment – analyze the assessment data provided ; Diagnosis – establish a priority nursing diagnosis related to the assessment data Planning identify a goal you would like your patient to achieve.. Interventions what can we do to help improve this condition? Identify some actions the nurse can take . evaluation evaluate the interventions and care provided. Did it help? (choose your own ending).

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