Help w/ head injury pt - Page 2

You really don't need your book to help you out. What you need to think about are what are your concerns for this pt......remember ABC priority as well as safety. Are you just doing one nursing diagnosis (care plan) or are you doing more than one? Injury/right sided weakness is high risk for falls, that is priority........you could also do some self esteem ones, you say shes a med student and now is burdened by this injury and may not be able to goto school......well i know if something happened to me right now how devestated I would be...but those nursing dx's are not priority......

why do you need your book, just always think...what are my concerns for my pt...and usually you will figure out your priority diagnosis...... good luck!

This patient has a closed head injury. When a patient receives a bump or bang to the head, the severity of the injury varies. We all know what the worst is: hemorrhage that requires brain surgery to remove the blood clot or death. However, there are many instances when there is bleeding into the brain and surgery is not performed. In those cases, the body is left to heal by it's own normal mechanisms. Also, remember that the brain is enclosed in the bony cranium. When there is injury involving velocity, as when someone is thrown from a vehicle during an accident, the brain (a tissue) gets slammed up against the hard bone of the skull. Cells of the brain get damaged and small capillaries rupture and bleed just like your arm or leg does when you slam it accidentally against a hard object. The result is a contusion. Most of you know a contusion by its common name of a bruise. Bruises occur on the external part of your body. Small capillaries are broken open and bleed for only small moments in time before they seal themselves off when a contusion or bruise occurs. Thus, you have a contusion of the brain. The injury is not severe enough for a surgeon to go in surgically. However, the injury to the brain cells result in swelling and death of some of the cells. And, that is where much of the mystery regarding what is happening with these kinds of patients comes from. The patient will lose consciousness within moments from the swelling of the brain cells from the trauma. The thalamus is part of the limbic system which is the primitive system of the brain that controls instinct and emotion. If this patient was experiencing bleeding into this area from contusion at the time of her injury it would explain why she was combative at the scene while she was conscious. As the swelling increases unconsciousness develops. Until they regain consciousness again, it is difficult to assess the full extent of all the brain damage because the brain controls so much of our functioning. Obviously, in the case of this patient, there is enough damage that there is some paralysis to the right side of the body. The patient is also experiencing problems with speech. It takes a good 6 months or more for the brain to completely heal and recover. As the swelling completely recedes the patient may regain some more of her old functioning back, but it doesn't sound very hopeful. She will, indeed, be in rehab for many months of PT, OT and probably speech therapy.

With these patients an appropriate nursing diagnosis to use is Disturbed Thought Processes R/T neuromuscular impairment. The definition of this diagnosis is "disruption in cognitive operations and activities." (page 204, Nursing Diagnoses: Definitions & Classification 2005-2006 published by NANDA International). According to Gulanick and Myers in their latest edition of Nursing Care Plans: Nursing Diagnosis and Intervention, 6th Edition, the nursing problems this diagnosis addresses included confusion, disorientation, inappropriate social behavior, altered mood states, delusions and impaired cognitive processes. People who suffer head injuries have some degree of confusion, disorientation, altered mood states and impaired cognitive processes. Defining characteristics that Gulanick and Myers also list with this diagnosis include the impaired ability to perform ADLs of self-care, altered sleep patterns, impaired memory, judgment, comprehension and concentration and altered ability to reason, problem solve, calculate and conceptualize. I worked on a neuro unit in my early RN years and I can tell you that people with closed head injuries and concussions definitely fit into this nursing diagnosis. Getting hit on the head may be exciting to watch at the movies or on TV, but it is a serious matter with life altering consequences.

So, yes, this patient has increased ICP. At the time that luv2shopp85 has had her, much of the ICP has decreased. Undoubtedly, some swelling of the brain still remains. However, what is also confusing is trying to figure out what might be a symptom of ICP and what is now permanent brain damage. Keep in mind that there are always degrees of the symptoms. So, while the patient was experiencing the worst of the symptoms, she was most likely in the ICU. This is why ongoing assessment of the patient is important. The symptoms of ICP are:

• changes in level of consciousness
• changes in breathing
• changes in vital signs
• headache
• nausea and vomiting
• visual disturbances that include changes in the pupil and eye movement
• nucal rigidity
• CSF draining from the ears or nose
• weakness and/or paralysis
• changes in sensation or feeling
• changes in reflexes
• seizures

Two other diagnoses that this patient could have are Impaired Physical Mobility R/T neuromuscular impairment and Risk for Injury R/T inability to control movement during seizures. Seizure activity is a complication of all brain injuries that should be planned for. When I worked on the neuro unit I saw just about every kind of seizure there was. And, we never knew which of our head injury patients were likely to convulse. It didn't matter that they were on medication or not.

Yay for Daytonite!!!!!

Yeah, this is what I was talking about.....safety is an issue b/c of right sided weakness...and Hx of falls so.. Risk for fall r/t hx of fall, right sided weakness........... risk for injury is alittle bit different......eg. Risk for injury:fall r/t right sided weakness ......and I think you said the pt. mentioned the weakness and if so you could change it to Risk for injury:fall r/t pt. statement "right sided weakness" or Risk for fall ..." "

and your other dx that you mentioned were awesome as well as daytonites (shes the best source ever btw!!!) but as a priority .... I think safety should be first, that's just what has been drilled into my head since day one. When I actually look at pt's charting though under nursing dx, safety is usually number 2 or 3 which I never understood why it wasn't number 1.

luv2shopp85. . .i think you're good to go with using disturbed thought processes r/t neurophysical changes secondary to head trauma amb disorientation to place, altered behavioral patterns, impaired ability to perform adls, memory impairment, inaccurate interpretation of the environment, distractability, difficulty with speaking and forming words, slowed responses to stimuli, difficulty concentrating, difficulty with comprehension and impaired physical mobility r/t musculoskeletal impairment, neuromuscular impairment, and limited strength aeb inability to move purposely within physical environment, limited rom of right extremities, decreased muscle endurance, decreased muscle control, decreased muscle strength, inability to perform actions as instructed, dragging of right foot with ambulation, limited ability to perform gross and fine motor skills, decreased walking speed, difficulty initiating gait, small steps when walking, shuffling of feet.

how about risk for injury r/t history of falls and loss of consciousness? then, your nursing inventions would include all the steps you need to take protect the patient from seizure activity—as well as from falling.

other ideas in wording the r/t part of risk for injury. . .ackley and ladwig list the wording for this with seizure disorder as risk for injury r/t uncontrolled movements during seizure (page 126, nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig). doenges, moorhouse and murr list the risk factors for this nursing diagnosis as altered consciousness, weakness, balancing difficulties, cognitive limitations, loss of large or small muscle coordination and/or emotional difficulties (page 211, nursing care plans: guidelines for individualizing client care across the life span, 7th edition).

by the way, you've got a spelling error. i've red bolded it above.
distractability should be spelled distractibility according to my spell checker.

Since it is allowed, I am going to disagree here. The poster has written a lot of DATA in the original "care plan" but the very fundamental bones of nursing is using nursing diagnoses instead of trying to find a medical diagnosis. Whilst there may be a lot of typing, energy etc. going into the care plan, it appears evident that unfortunately the OP does not grasp the essential bottom line. Hence, "see your instructor ASAP."

i am always curious as to how people make a determination that others might be asking forum members to do their homework. so, please, tell me, how do you determine this? i really want to know.

i maintain a list of people that i question might be doing this. before i would even think of publicly chastising them, i do some assessment and investigation of my own first. sometimes that involves answering their first question or two. but often by a third question, and in the frequency they post, their motives become pretty obvious. i have a list taped to my computer of those who i believe are looking for forum members to do their homework for them and i eventually stop replying to their posts. and, you know what? so do the other regular members. and, they fade away.