Help w/ head injury pt

  1. Can someone help me figure out what exactly was wrong with my patient? I waited until 2 days before I go back to school to do my maxi map/care plan and now I'm kicking myself big time. I'll tell you the history of my patient...

    She was an 18 yr old victim in motor vehicle accident. She was unrestrained and in the back seat and was thrown from the car. Here is some of her history as stated by her chart: She was combative at the scene and moving all extremitiies. Airway was established. Repeated attempts at ET tube intubation did not work and a combi-tube was placed. Pulse ox was 100% throughout the transport to the hospital. Strong bounding femoral pulses bilaterally and dry skin. Pupils 7 mm and slluggish before arrival. At arrival pupils were 4 mm bilaterally and slow to react. There were few external signs of trauma but did have a swollen right knee. GCS was 3 but had receivedc pharmacologic paralytic agents. In the abdomen arogastric tube was placed. Foley was passed and showed hematuria.

    Chest Xray, pelvic xray, and lateral cervical spine were normal. CT scan of the brain documented the presence of severeal punctate contusions of the left temporal lobe as well as a moderate sized contusion of the right posterior segment of the internal capsule and the right thalamus. The impression of the Xray was: Intracranial contusion, pulmonary contusion. Also showed hermorrhagic contusions in temporal and frontal lobe with lower lung pneumonia.

    Now I do not understand what this means! I am trying to do a maxi map/care plan on this patient but first i ahve to understand what all this means. Then I have to use all of the possible nursing diagnosis for her, all her signs and symptoms, and labs and i have to write all the interventions.

    When I took care of her she had been in teh hospital for a week and she had just started speaking 2 days ago. She could only answer with one word and had trouble speaking and forming words. So she was showing some aphasia. She seemed as though she was some what paralyzed on her right side. She just kind of dragged her right arm and when her mother got her up to walk her to the bathroom the daughter required maximum assistance to ambulate and dragged her right foot in a sluggish way as compared to the rest of her body. She had an unsteady gait and could not walk on her own. She got tired really easily. Her diagnosis on the chart said cerebral injury/pneumonia. She had a foot and hand splint for her right side. She had to be upright for all meals and had to be supervisd. The only meds she was on was keflex, dilantin, and tylenol prn for pain.

    In report it was said that she had right sided weakness so I guess she wasn't exactly paralyzed. The nurse told me she had a subarachnoid hemorrhage. She slows but will respond and knows her name and age. She is able to follow simple commands. She is awake and alert but did not know where she is. She is incontinent and wears a brief. She can move around in her bed and stuff her self but she requires maximum assitance when getting out of bed. The doctors said that she would have to undergo agressive rehab and that even after that she may never make it back to her functional ability she had before. I felt bad for the poor girl, she was studying premed at college and was a freshman. Now she may never go back..

    Okayh im sure i've given you enough informatino now but my question is where do i start with this care map? We need a main medical diagnosis and then a secondary one if applicable. I am not seeing anything in my care plan books for head injury. Does it sound like she had increased ICP? ---->there was never anything mentioned about increased icp though, Subarachnoid hematoma? Just a plain brain injury? Spinal Cord injury?
    I can't find anything in my care plan books or my textbooks and its driving me nuts.

    When I looked up head trauma in my care plan book i was able to find a few diagnosis but none really r/t my patient:

    Decreased intracranial adaptive capactiy ... i dont even think thats nanda approved
    Risk for fluid volume defecit .... she didnt have this
    Risk for excess fluid volume ..... again does not apply to her, she urinates fine
    Risk for ineffective airway clearnace ..... possibly could use this
    Risk for seizures .....i can use this because she is on antiseizure meds
    Risk for imbalanced nutrition: less than body requirements .... again doesn't really relate to her

    Potential diagnosis I could use are:
    Risk for disuse syndrome r/t right sided weakness/neglect
    impaired mobility, or impaired walking
    ineffective coping
    Self care defecit: bathing hygiene dressing and grooming
    Acute pain
    Acute confusion
    Impaired memory maybe
    Risk for aspiration
    Risk for falls
    Risk for injury


    If someone could help me out i'd realllllllly appreciate it! thanks
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  2. 33 Comments

  3. by   ukstudent
    What nursing care did you give her? That should be your care plan. Consentrate on what you did, how that effected her and if you had to change what you were doing to get better results.
  4. by   luv2shopp85
    Well I know what care i gave her is what I would use for the interventions for the nursing diagnosis. But I'm having trouble with the medical diagnosis and finding ideas for the nursing diagnosis. Usually if say, I had a patient with a stroke I could look up stroke in my nursing care plan book and it would give me many different diagnosis and I can use whichever applies to my patient. But with this patient's head injury i am not finding anything in my books or any ideas.
  5. by   ukstudent
    What I was trying to say is that you are doing the care plan backwards. Nursing is not medical, at least it is not meant to be. Look at what nursing care you gave. What system or condition did that effect. That system will give you the correct nursing diagnosis.
    If you go by medical diagnosis, get a nursing diagnosis from that of say ineffective breathing pattern but your nursing care was checking urine output, then you will be left with jibberish.
    Your nursing care will lead you to the correct nursing care plan. I am probably not explaining it well. But think nursing not medical.
  6. by   jov
    Quote from luv2shopp85
    If someone could help me out i'd realllllllly appreciate it! thanks
    um...I could be wrong but it appears you are asking US to do YOUR care plan?

    the best I could recommend is to see your instructor ASAP
  7. by   luv2shopp85
    I am not asking someone to do it for me im asking for ideas and/or suggestoins to the ideas that i have already listed for nursing diagnosis. I am unsure of where to start with this and the correct diagnosis to use. My care plan books usually help me but they are not helping me with this because i can't find her general medical diagnosis in any of them.
  8. by   rn/writer
    Quote from jov
    um...I could be wrong but it appears you are asking US to do YOUR care plan?

    the best I could recommend is to see your instructor ASAP
    The original post shows that this poster has put plenty of thought and effort into working on her care plans for this patient. Needing help to understand is not the same as asking us to do the work for her.
  9. by   rn/writer
    I agree with UK student.

    One of the most common mistakes with student care plans is the misunderstanding of the difference between medical diagnoses and nursing diagnoses. If the diagnosis would require you to intervene in a way that only an NP or physician is allowed to, then it is not a nursing diagnosis.

    Look at how you, as a nurse, can have an affect on the patient. Example: right-sided weakness. That is a medical diagnosis. You can't order an MRI to help determine the cause. You can't order PT to help the patient regain strength. You can't order splints.

    The nursing approach to this problem would focus on things the nurse can do: insure patient's skin integrity while wearing splints, provide proper positioning in bed to prevent contracture or pressure wounds, help patient to transfer to avoid further injury, etc.

    If you start from the top (medical diagnosis) and go down, you will encounter a lot of distraction and confusion.

    If you start from the bottom (what can I as a nurse do for this patient and her basic ability to function) you can always enlarge upon your findings, but you stand a much better chance of staying within the realm of nursing concerns.
  10. by   JentheRN05
    There are several you can go with
    Alot of risk for scenarios. Because the injury has already occurred, you have to look at what YOU can do to prevent further injury. Because of her 'brain bleed' she is at risk for increased ICP. Also - think about the areas that was injured in her brain. Think how that will affect or possibly affect her demeanor. Risk for injury (to self and others) would be one obvious one. Simply sorting out the areas of the brain that was injured and working from there should help alot. Remember this is a normally young, and healthy 18 year old. What will it do to her image?
    Think about what YOU can do and work from there. Given you a couple to go on. It should get you thinking in the right way.
    Last edit by JentheRN05 on Jan 2, '07 : Reason: Adding other thoughts
  11. by   JentheRN05
    Also - remember her injuries were NOT only in her head, she also had pneumonia as well. So go off on those too to PREVENT further injury and control the injury she already has (within nursing scope of course).
  12. by   srg4784
    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!
  13. by   Daytonite
    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.
  14. by   srg4784
    Yay for Daytonite!!!!!

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