3. CNS
حسی عصبی سطوح و
•
بندی تقسیم
عصبی سیستم
CNS
:
• brain 12
• -brain stem (mid brain-pons-
medulla)
• -spinal cord 31N
• Low motor neuron of 2-3-4 in the mid
brain
• Low motor neuron of 5-6-7 in the pons
• Low motor neuron of 8-9-10-11-12 in
the medulla
3
11. A. Clinical disability
Clinical diagnoses of cognitive disabilities include Traumatic brain injury (TBI), and
even dementia, Autism, Down Syndrome.
Less severe cognitive conditions include attention deficit disorder (ADD), dyslexia
(difficulty reading), dyscalculia (difficulty with math), and learning disabilities in general.
B. .Functional disability.Some of the main categories include deficits or difficulties with:
Executive Functions (initiation, problem solving .processing speed , planning)
Memory ( visual. auditory , working memory)
Information processing
Visual Processing
Attention
11
شناختی اختالالت از دیگر بندی طبقه
Classification of cognitive impairment
23. Cognitive Rehabilitation
•
is a complex collection of techniques designed to enhance perception, attention, comprehension,
learning, remembering, problem solving, reasoning
•
Rehabilitation strategies
23
35. NURSING DIAGNOSIS
➢ Acute pain related to altered brain or skull tissue. Domain 12 • Class 1 • Diagnosis Code 00132
➢ Ineffective cerebral tissue perfusion associated with brain injury related to increased ICP Domain 4 • Class
4 • Diagnosis Code 00201,
➢ Imbalanced nutrition, less than body requirements, related to, fluid restriction, and inadequate intake
Domain 2 • Class 1 • Diagnosis Code 00002
➢ Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, immobility, or
restlessness Domain 11 • Class 2 • Diagnosis Code 00046
➢ Disturbed sleep pattern related to brain injury and frequent neurologic checks Domain 4 • Class 1 •
Diagnosis Code 00198
➢ Self-care Deficit: decreased strength/endurance, perceptual/cognitive impairment,
neuromuscular impairment,, depression. Domain 4 • Class 5 • Diagnosis Code 00108 Bathing self-care
deficit/ Domain 4 • Class 5 • Diagnosis Code 00109 Dressing self-care deficit/ Domain 4 • Class 5 •
Diagnosis Code 00102 Feeding self-care deficit/ Domain 4 • Class 5 • Diagnosis Code 00110 Toileting self-
care deficit
35
36. nursing care plan and interventions for a patient with a TBI
➢ .Maintain ICP monitoring, as indicated, and report abnormalities.
➢ Maintain patent airway; assist with intubation and ventilatory assistance is needed.
➢ Turn the patient every 2 hours and encourage coughing and deep breathing.
➢ Apply firm pressure over puncture site for subdural trap, and observe for drainage and
dressing.
➢ Suction the patient as needed..
➢ Feed the patient as soon as possible after a head injury and administer histamine-2
blockers to prevent gastric ulceration and hemorrhage from gastric acid hypersecretion.
➢ If the patient is unable to swallow, provide enteral feedings after bowel sounds have
returned.
➢ Elevate the head of the bed after feedings, and check residuals to prevent aspiration.
➢ Monitor respiratory rate, depth, and pattern of respirations.
36
54. • 7 .Ackley, B. J., Ladwig, G. B., Msn, R. N., Makic, M. B. F., Martinez-Kratz, M., &
Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide
to Planning Care. Mosby. [Link]
• 8 .Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical management
for positive outcomes (Vol. 1). A. M. Keene (Ed.). Saunders Elsevier. [Link]
• 9 .Carpenito-Moyet, L. J. (2006). Handbook of nursing diagnosis. Lippincott Williams
& Wilkins. [Link]
• 10 .Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. (2017).
Medical-surgical nursing: Assessment and management of clinical problems.
• 11 .Urden, L. D., Stacy, K. M., & Lough, M. E. (2006). Thelan’s critical care nursing:
diagnosis and management (pp. 918-966). Maryland Heights, MO: Mosby.
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