Help w/ head injury pt - page 3

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... Read More

  1. by   jov
    Quote from daytonite
    if people posting for help with homework bothers you so much then report it to the moderators and the administrator of the forum--please.

    i wanted to discuss this with you privately, but you have disabled your private messaging.
    i am not arguing with you. you specifically asked me a question which you indicated (sincerely, i believe?) you really wanted to know. it's unclear to me why you are uncomfortable discussing this publicly on the board, but in the past there have been incidents of quite abusive messages sent privately.
  2. by   Daytonite
    i just want to announce that people who go about deliberately taunting, scoffing, jeering, provoking, mocking, flouting, and deriding me or my efforts on the allnurses forums merely for their own sport and/or to get their jollies for whatever twisted reason(s) get a place on my ignore list where all their words just get sent to the cyberspace bone yard and never read by me.
  3. by   moongirl
    Quote from daytonite
    i just want to announce that people who go about deliberately taunting, scoffing, jeering, provoking, mocking, flouting, and deriding me or my efforts on the allnurses forums merely for their own sport and/or to get their jollies for whatever twisted reason(s) get a place on my ignore list where all their words just get sent to the cyberspace bone yard and never read by me.
  4. by   Daytonite
    wanted to post some information about closed head injuries, contusions in particular, that i got from pathophysiology: a 2-in-1 reference for nurses so those of you who might need or want to know this information would have it.

    closed head trauma is when the head strikes a hard surface or a rapidly moving object strikes the head and no brain tissue is exposed to the external environment. hair, skin of the scalp, bone of the cranium, the meninges and cerebrospinal fluid absorb some of the force of a physical blow to the head. neck injury is also likely to occur and should be ruled out. when there is closed head injury it is usually a coup-contrecoup injury where the head hits a relatively stationary object causing injury of the tissues at the point of contact (coup) and then the remaining force pushes the brain against the opposite side of the skull causing a second impact injury (contrecoup). contusion occurs during contrecoup often damaging the upper midbrain and areas of the frontal, temporal and occipital lobes of the brain.

    contusion is a closed head injury in which there is bruising of brain tissue that is more serious than a concussion. it results from arterial bleeding. blood accumulates between the skull and the dura. normal nerve function is disrupted in the bruised area. signs and symptoms may include scalp wounds from the direct injury. there will be labored breathing and loss of consciousness secondary to increased pressure from bruising at the time of the injury. there will be drowsiness, confusion, disorientation, agitation or violence from increased intracranial pressure associated with the trauma. hemiparesis (hemiplegia) related to the interrupted blood flow to the site of the injury can occur. there may be decorticate (indicating problems with the cervical spine or a cerebral hemisphere) or decerebrate (indicating problems with the midbrain or pons) posturing from cortical damage or hemispheric dysfunction. there may also be unequal papillary response due to brain stem involvement. ct scanning will show changes in tissue density and possible displacement of surrounding structures with evidence of ischemic tissue, hematomas and/or fractures. eegs will show progressive abnormalities by appearance of high-amplitude theta and delta waves directly over the area of contusion. the major complications of contusion are increased intracranial pressure and respiratory depression and failure. treatment is supportive and will include observations to detect changes in neurologic status. surgical treatment is only indicated if hematomas expand. diuretics, such as mannitol, may be given to reduce cerebral edema.

    general nursing considerations include establishing and maintaining a patent airway. watch for any csf draining from the ears, nose or mouth. check the linens and pillowcases for evidence of any csf leaks. if there is drainage on linens, look for a halo sign. do not encourage blowing of the nose. do not encourage any activity that would increase pressure in the head such as bending over, coughing or lifting heavy objects. institute seizure precautions. no sedatives or narcotics should be given because they increase icp, depress respiration and mask neurologic changes. fluid intake should be restricted because of intracerebral swelling.
  5. by   marjjack
    I know this post is old, but I am a new nursing student and found it very helpful. I am working on my very first care plan ever (yikes!) and had some similar complications. I was wondering if anyone out there is still following this, if I could ask a few follow up questions. The care plan I have to develop is 7 forms about the various areas of care I will give a patient. The first form is basic patient information and I feel like I understand/have completed it correctly. The second form is identifying the most important nursing problems, developing a nursing diagnosis, and interventions. I feel like I have that under control. Form 3 is vitals, and form 4 is patient assessment. Again, I feel like I understand those forms and have filled them out correctly. Form 6 is the actual care plan, with nursing diagnosis, outcomes, interventions, and evaluation. Got it. Form 7 is meds, uses, dosages, and considerations. I feel like I've got that under control. So my real issue is form 5, Pathophysiology. The form asks for the primary medical diagnosis, the etiology, the signs and symptoms, relevant labs/radiologic tests, common medical/surgical treatment interventions, nursing care implications/interventions, and related secondary medical diagnoses. So the issue I am having with the form is putting together the medical and the nursing. I know what I did for my patient, since it was the first day, I just gave him a bath, changed his brief, changed his linens, took vitals and assisted with med administration. My nursing diagnosis was risk for falls (completed prior to meeting/working with the patient) because he has a seizure disorder and has full bedrails and hand mitts at all times, but does get into a special chair daily. His primary medical diagnosis is intracranial injury of other/unspecified nature, due to a gun shot wound to the head 16 years ago. So for etiology, I put open, focal traumatic brain injury. For the signs and symptoms, I listed the signs and symptoms that would have been evident right after the injury. For the labs, I put test or labs that would have been performed during the initial hospitalization. For medical/surgical treatments, I again used the treatments that would have been used directly after the injury. Now for the Nursing care implications and interventions. I know and several of my books discuss what nursing care would be given in the short term after the injury. But for my situation, he is in the long term care part and I am not sure what to use. He has a PEG tube and has had pneumonia related to aspirating on his tube feed in the last three months, he also has a daily breathing treatment with a nebulizer, he is repositioned in bed every two hours to protect his skin integrity, his brief is checked and changed every two hours to prevent skin breakdown, his vitals are taken daily, he is bathed per schedule, he is placed in a special chair daily (I think), and he is given medications for pain, anticonvulsants, and nausea and vomiting. Is this would I would list and is this an acceptable way to phrase these interventions? The patient is non verbal, has very little voluntary motor control (he can move his head from side to side, focus his eyes, and move his left arm, but has difficulty controlling the movements), and is total care. I appreciate any suggestions on wording and/or interventions I might not be seeing.
  6. by   jonesecho
    Quote from luv2shopp85
    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
    Much of this woman's deficits would be from the head injury. when there are contusions or bruising or consucssions, there is swelling or edema which causes pressure, which causes injury and malfunctions in the brains and the nervous system, thus the ss of stroke or cva. as swelling goes down and healing occurs she will probably get some functions back as long as they weren't permanent damage. I question why she was not getting solu-cortef per iv for swelling. rehab is important so she keeps function and loses less. depending on the parts of the brain most affected and how well she heals will determine her recovery. the weakness can be from the brain injury and nerves/muscles-but pneumonia alone will make a person very tired. she may shock some of her caregivers. I have seen people like this regain most of their capabilities. I hope this will be the case. the trauma of the accident probably cause the hematuria, and then having a catheter could cause some incontinence. hopefully that will return to normal also. your second group of nursing diagnosis all look good. i hope this was some help.
  7. by   rainman132
    I can think of many nursing diagnosis based on what you have stated about the patient. Don't always rely on what the book says. Always consider the problems present on the patient.


    increased ICP related to subarachnoid bleeding
    Activity Intolerance related to right sided weakness
    Impaired gas exchange due to excessive secretions???(pnuemonia)
    Ineffective airway clearance??? (pnueamonia)????
    Impaired verbal communication due to brain injury
    IMpaired physical mobility related to right side weakness
    Acute pain r/t head/knee injury????
    Functional urinary incontinence???
    Hyperthermia if there is fever
    IMpaired skin integrity if there is any

    Risk for fall
    Risk for constipation
    risk for impaired skin integrity - splints /bed sores
    Risk for social isolation
    Risk for injury
  8. by   Esme12
    Rainman....welcome to AN!

    Great ideas....this is a 5 year old thread but there are always much to learn by revisiting.