Brain Dead Pt Nursing DX

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Hello everyone,

Just had a question about nursing diagnosis for a brain dead patient. Please check if my nursing dx sounds ok..I'm not quite sure.

My patient suffered severe brain injury d/t MVA => epidural, subdural, subarachnoid hematoma, tentorial shift. Was pronounced brain dead. Family agreed for organ donation.

1) Ineffective airway clearance r/t absent cough, gag reflex, brain death aeb adventitious lung sounds(interventions: suctioning, auscultating, etc)

2) Decreased cardiac output r/t intracranial hemorrhage, hematoma? aeb declining BP, increased heart rate (interventions: giving meds like Dopamine, Neosynephrine as ordered to preserve organs for transplant, etc)

3)

Please help.

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Specializes in Hospice / Psych / RNAC.

Is this for school; if not doesn't the facility already have care plans that reflect what's happening? Anyway I would like to see something that indicates the reason he is not breathing like irreversible cessation of brain function blah blah declared legally dead blah blah...and also about the organ donation, what's being done to keep him steady such as meds given to maintain HR/BP etc...that's where number two is good but take it further and another about the family, coping etc...

When I read what you have and didn't know the situation I had no idea the guy was declared brain dead and there may be potential organ donation. Number two is fine but take it further with related to due to legally pronounced brain dead. Then take off with another about organ donation which is why you're giving the heart meds anyway to sustain the organs or something........ Hopefully someone else can come up with something for ya.

I admit I don't know about nursing Dx's that much. Anyway sorry about your patient.

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Specializes in CRITICAL CARE.

Is the brain death patient being comfort cared or are they still keeping life support? If its comfort care, decreased CO and ineffective airway clearance would not be your priority diagnosis but more on psycho social relating to the family, pain management, deficient knowledge, etc. I'm guessing comfort care since organ donation was brought up and in that case life support, antibiotics, and pressors might be used to keep the organs functional but I would not consider it my first choices because patient and family care&comfort comes first.

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Specializes in ER, Trauma ICU, Peds ICU.

Ok so let define brain death- the absence of blood flow to the brain it is a legal form of death and TOD is the time the brain death assessment was done.

Airway clearance due to no gag would not work, due to the fact you should have an airway ( ETT or Trach). But you could use impaired gas exchange r/t need respiratory ventilation. Potential for hemodynamic instability r/t multisystem organ failure. And some type of coping for the family r/t death ( the pt is dead if brain death has been declared).

By the way comfort care is not an potent dx if brain death has been declared. There is no need for pain meds or sedation, the pt is dead ( brain dead is dead is dead).

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Specializes in MCH,NICU,NNsy,Educ,Village Nursing.

Isn't brain death a medical diagnosis? If so, I don't think that in itself can be included in the nursing diagnosis--you can't "fix" brain death. But, you can help with comfort measures such as suctioning, etc. So, if I used number 1, I'd leave out the "brain death" and focus on the "nurse fixable" things such as airway clearance. So sorry for your patient's family, and for you as a student to encounter this. It must have been difficult.

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Listed below are some examples for your nursing diagnoses that I would suggest:

1. Ineffective Tissue Perfusion (Cardiopulmonary) r/t decreased circulating blood volume aeb death resulting from compression of vital areas within the brainstem that control respiratory, vasomotor, and cardiac function.

2. Decreased Cardiac Output r/t altered stroke volume aeb arrhythmias (tachycardia), decreased BP, cold, clammy skin, decreased peripheral pulses, pale, grayish color of skin, and adventitious lung sounds in RLL and LLL.

*The aeb factors listed in #1 was another "fancy" way of stating many of the same aeb factors listed in #2!

The reason why I'm suggesting these nursing diagnoses is because of the fact that your patient was declared brain dead and was going to be an organ donor. Since this is the case, to me the most important intervention would be to maintain adequate circulation and profusion to the organs. So that was my line of thinking. Since I'm not sure of your patient's actual symptoms, I made some up some to use in the examples.

Some additional info when doing care plans--If your using a Nursing Diagnosis Handbook and you determine what your nursing diagnosis is, there are related to factors listed pertaining to that particular diagnosis. These r/t factors explain what the patient's "problem" is.

Okay, let's clarify this a little bit better. For example, using our example of the nursing diagnosis of Decreased Cardiac Output, the r/t factor ("problem") is the patient's altered stroke volume. (Read up on what stroke volume is and the factors that encompass it and the effect on cardiac output). Trust me, it'll make more sense after you read it!). The result of this altered stroke volume is decreased cardiac output. Hence, our nursing diagnosis. Hope this makes more sense.

Okay, so here's some more additional info: aeb are those symptoms that are specific to your patient and support your nursing diagnosis. It's like making a hypothesis and using specific facts that support your theory.

So again, we will use our example of decreased cardiac output (hypothesis) and list the symptoms (specific facts) that our patient is experiencing: Decreased BP, tachycardia, cold, clammy skin, decreased peripheral pulses, etc. These specific symptoms under our aeb helps to support our nursing diagnosis. Hopefully, this will now be easier to understand.

It is very important to make your symptoms specific to your patient. For you will use these later on to evaluate your patients progress and to determine whether to continue with the current plan of care or revise it.

Okay, I've got to conclude this and get off my "soapbox" as I spent about 3 hours on this and I was supposed to be working on my resume!!

Take care and if you have anymore questions or need help, please PM me and I'll be glad to help!!

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Specializes in ED, CTSurg, IVTeam, Oncology.

trekkie nursing diagnosis: "he's dead, jim..." :D

http://www.youtube.com/watch?v=qjqwhwp0oji

sorry, dark gallows humor i know, but i couldn't resist... :jester:

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Specializes in Hospice / Psych / RNAC.
trekkie nursing diagnosis: "he's dead, jim..." :D

http://www.youtube.com/watch?v=qjqwhwp0oji

sorry, dark gallows humor i know, but i couldn't resist... :jester:

:yeah:

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Specializes in Oncology; medical specialty website.
trekkie nursing diagnosis: "he's dead, jim..." :D

http://www.youtube.com/watch?v=qjqwhwp0oji

sorry, dark gallows humor i know, but i couldn't resist... :jester:

as a former ed nurse, i have to say i loved that.

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Specializes in cardiac.

risk for aspiration

self care deficits

activity

RF dvt

RF pressure ulcers

RF infection

don't forget safety, love and belonging needs of the family like grieving

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