Outcomes for chronic confusion from head trauma?

[jringer]

I had an 85 yr old pt. who fell and hit her head. Her CT scan was an absolute mess!! I have chosen a diagnosis of

Chronic confusion R/T disturbances in cerebralintegrity secondary to head trauma AEB lethargy and confusion. My assessment is as follows:

General: VS: 98.6 F, axillary; 91 HR; 16 RR; 151/71 BP; 94%SpO2 on R/A; 0/10 pain reported

Neuro - Alert, oriented x1 (self). PERRLA, 3mm, brisk. Nares symmetrical, patent. Nasal membranes dry and pink, no drainage. Oral mucous membranes dry, cracked and pink. Oral care/swabs used to comfort pt. Pt tired, confused, quiet, follows commands,clear speech. Glasgow scale score 13. Pt. prescribed Keppra 500mg IVPB Q12h toprevent seizures.

Respiratory - Trachea midline. Breathing unlabored. Chest expansion symmetrical. Breath sounds clear in upper and lower lobes,anterior, patient refused posterior check at this time.

Cardiac - S1 and S2 audible, regular. Apical heart rate 90, S1 correlates withradial pulse. No murmurs noted.

Capillary refill

GI - Pt claims to be thirsty. Strict NPO diet until family decides courseof action. Bowel sounds present in x4quadrants, normoactive. Last bowelmovement on 09/27/2012. Abdomen soft,flat, non-distended, non-tender.

GU - Patient is reported incontinent with urinary andbowel. Pt. has 14 fr Foley catheter withadhesive leg strap. Urine output 425mlfor 10 hours. Urine clear, yellow, nosedimentation, no odor noted.

Skin - Skin warm, pink, and dry. Qaurter size bruise located on left hand,ecchymosis noted around left antecubital from pt. pulling out peripheral IV inthe ED. Turgor is tenting. Edema, +1 in lower right extremity. Heels were soft, a little mushy, pt. legselevated off bed with pillow to relieve pressure.

Musculoskeletal - UE: muscle strength 4/5. Strong Grip. Radial pulses equal bilaterally+2. ROM active in all UE. LE: muscle strength 3/5. ROM active in all lower extremities.

IV Access - 20g peripheral IV in right forearm with D5W 0.9%NS at 80ml/hr continuous infusion, covered with occlusive dressing. Site ispain free, non-edematous, non-red, no drainage.

Pain - Patient states 0/10 pain rating

Psychosocial/Spiritual - Family at patient bedside. Continuously redirecting patient to time,place, and situation. Chaplain , socialservices, and palliative care consult scheduled.

Safety issues - Patient on bedrest. Call light within reach. Patient and family instructed to use calllight if she needs anything. Familyverbalized understanding. Patient wearingyellow non-slip socks. Walkways clear ofdebris. Bed locked and in low position. Identification/medication band located onleft wrist. Bed alarms on.

Teaching Needs - Family is waiting on consultations withcare team to determine plan of care. While waiting, family was taught ways to comfort patient, i.e. swabbingmouth, elevating HOB.

Looking through my NANDA book, the example for outcome is for the patient to participate to maximum level of independence in therapeutic milieu. Since I only had her for one day and the family is considering palliative care, does this even seem appropriate? I also have to make it measurable and am just at a loss.

Chief Complaint: confusion from fall; ICH - Patient wasfound in home lying on floor covered in own feces and urine. It is estimatedper family that patient was on floor for approx. 3 days. Patient could notstate why she was on floor, no recollection of fall. Patient was conversantwith confusion. Head CT scan showed ICHthroughout the left side. Patient was 100% independent prior to fall. Family has changed code status from Full toDNR and are considering palliative care for patient. Awaiting consult with care team and family todecide treatment plan for patient.

The other diagnoses I am writing about are concerning dehydration, impaired skin integrity, and risk for further bleeding. Just need help getting an appropriate outcome when I see not much chance for improvement.

[Esme12, ASN, BSN, RN]

Is her confusion chronic with an acute injury? Isn't she essentially in the acute phase other injury? Is she safe? Has this cause a self care deficit? Is she at rosk for re-bleed? Is there family stress? Are they coping well? Does she have a decrease intercranial capacity?

What do you think?

[MrChicagoRN, RN]

What does 100% independent at home mean exactly? Cooking, cleaning, paying the bills, shopping & driving; or simply safe at home without supervision?

How long ago was the fall, and has she shown any improvement in that time? Has it been long enough to accurately predict not much room for improvement?

[jringer]

From what the family states, 100% independent is cooking, cleaning, driving herself, etc. She went to lunch on Monday -> grandson came to mow grass on Thursday afternoon. Her pill container (separated by the day) showed she hadn't taken meds since Monday morning and there were papers stacking on the porch which she reads daily. By their estimate, she fell and hit her head on Monday after lunch sometime. They found her lying in her own excrement but conversant. No bones were broken, just ICH. She came in the ED on Thursday afternoon and was admitted early Friday morning and I saw her then.

Based on Neurologists findings, amount of bleed, and age of patient - they gave little hope for improvement. Neurology told family that the only reason she wasn't brain dead was because of age related brain atrophy.

Risk for re-bleed is certainly viable which is why I have risk for bleeding as one of my diagnoses. Can I put Risk for re-bleed?

The confusion state, which was said will now be chronic, will definitely cause a self-care deficit. Should I write the diagnosis based more around the self-care deficit instead of the confusion? For my assignment, I have to put all of this in a concept map form, showing how they all interrelate. It's pretty simple getting the dehyrdation, skin breakdown, and risk for bleeding to all tie in together. I'm just stuck getting to the 4th pertinent diagnosis that goes along with Intracranial hemorrhage.

[Esme12, ASN, BSN, RN]

While her long term prognosis is poor her confusion is acute. What is a ICH? Was is a subdural or epidural? What are her dificits other than confusion? Can she do anytihn g for herself?

What is the NANDA definition for bleeding? IS there a blood volume risk?

Would her condition cause a "progressive functional deterioration of a physical and cognitive nature. The individual's ability to live with multisystem diseases, cope with ensuing problems, and manage his or her care is remarkably diminished."........or adult failure to thrive? or will her Impaired Memory: Inability to remember or recall bits of information or behavioral skills; impaired memory may be attributed to pathophysiological or situational causes that are either temporary or permanent.... that she will "Experience of forgetting; forgets to perform a behavior at a scheduled time; inability to determine if a behavior was performed; inability to learn new information; inability to learn new skills; inability to perform a previously learned skill; inability to recall events; inability to recall factual information; inability to retain new information; inability to retain new skills"

Is she at Risk for decrease in cerebral tissue circulation: Risk Factors......Abnormal partial thromboplastin time; abnormal prothrombin time; a kinetic left ventricular segment; aortic atherosclerosis; arterial dissection; atrial fibrillation; atrial myxoma; brain tumor; carotid stenosis; cerebral aneurysm; coagulopathy (e.g., sickle cell anemia); dilated cardiomyopathy; disseminated intravascular coagulation; embolism; head trauma; hypercholesterolemia; hypertension; infective endocarditis; left atrial appendage thrombosis; mechanical prosthetic valve; mitral stenosis; recent myocardial infarction; sick sinus syndrome; substance abuse; thrombolytic therapy; treatment-related side effects (cardiopulmonary bypass, medications

Skin integrity....she is incontinent.

Seizures/confusion...safety skin is tenting...she's dehydrated

See where this is going?

Remember what I told you before. The care plan is about what THE PATIENT needs. What behaviors the patient exhibits. The assessment of THE PATIENT.