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
