Nursing Dx for axonal brain injury

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my patient suffered from a traumatic brain injury. axonal brain injury. this is my 1st semester nursing student. in picking my nandas I wanted to choose what i treated. upon entering the room, her eyes were extremely watery, my interpretation were tears were streaming down her eyes, she cannot communicate verbally, spontaneous tracking, comes and goes, immobile. when i seen her this way i informed my nurse. she stated she would give her meds first prior to other patients, and would give her pain medications. when hearing report the night nurse stated that her bp and heart rate were stable and she was not grimacing. so pain meds were not given over a 12 hour shift. but were ordered every 4 hours. I then went back into the room for my assessment. patient had a stage 1 ulcer on the back of her head, contracting on bilateral hands, her splints were on but her fingers curled. later on while changing her hard ball of stool. so when i thought of my Nandas i figured pain related to traumatic brain injury as evidence by patient crying, grimacing. constipation related to pain medications as evidence by formed stool. and impaired physical mobility related to brain injury as evidence by contracting of bilateral hands. my nursing instructor said how do you know she is in pain? her bp was normal. pulse was normal. and I've been reading on axonal brain injury. how do you know if your patient is in pain or not? in my med surg book it states to not use bp, p, and facial expressions as a basis to hold or give meds. how would i know if my patient was in pain or not? she had splenectomy, gastrostomy tube, trach. bilateral pneumothorax. left parietal fracture and orbital swelling, left temporal bone fracture left and right orbital fractures. if you were a nurse would you continue with physicians orders and continue pain meds as prescribed...or hold the meds? and if you were me a nursing student. my pull is to continue to use the pain as a nanda. also, patient has been in our care for 6 weeks.

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Specializes in Pediatrics, ER.

Your poor patient. That is a brutal injury to overcome....I'm guessing it was from a car accident? You can't always go by vital signs as an indicator for pain because these patients are usually on meds to control storming, which in turn lowers their BP and pulse. Contractures in of themselves tend to be painful, with or without splinting. I would definitely continue pain medications. If her injuries were 6 weeks ago that's pretty fresh, not to mention patients with these extensive injuries go on to have chronic, debilitating pain. In my opinion, that nurse was wrong to not use the pt's nonverbal cues like facial grimacing as an indicator of pain, at the very least.

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Specializes in Pediatrics, ER.

P.S., keep in mind that a patient's BP/pulse don't have to be out of normal range to be abnormal for the patient...if she usually has a pulse of 60 and you see she has a pulse of 80, that could be an indicator of pain for her....it's about knowing the patient's norms and being in tune with her.

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Specializes in Pediatrics, ER.

P.P.S....I would go more on the lines of "impaired physical mobility r/t axonal brain injury, a/e/b absent reflexes, absent muscle tone, inability of patient to reposition herself," etc....also "constipation r/t pain medication a/e/b hard formed stool..." a formed stool in itself is not necessarily a sign of constipation. Does the patient have any problems maintaining her electrolytes? You could make a nursing dx based on that....you can also do impaired respiratory function r/t brain injury a/e/b presence of tracheostomy tube, decreased or absent respiratory effort, etc....risk for imbalanced nutrition; less than body requirements, a/e/b inability of patient to self-feed, weight loss...risk of aspiration r/t impaired swallowing a/e/b presence of trach, inability to handle oral secretions, etc...

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Yes it was from a car accident. But she has improved from the first day I cared for her. and But in investing this brain injury thats the trend...she will still have so many other health issues/impairments. But I feel good about the care I gave her. the day I had her is what my instructor wants me to base my nandas from. So she had no issues with trach, lung sounds were good, bowel sounds good. her pain was my main concern. then once the meds were onboard I did her ADLS. I noticed the constipation after changing her diaper, at that point she had no foley. hep lock. so my nurse that day gave her the pain meds. which i felt good about. I find that when they are in pain is when i have the most anxiety. So we aren't allowed to use medical diagnosis as our related to. which makes it harder for my nandas :(. it has to be what i observed that day. her bp for the last 3 days was 122-130/ 60-84. her pulse from 79-110. it was 110 during grimacing and crying for me. respirations are always 20-24. I just figured if the dr ordered it. administer right? unless there was a decrease in her respirations and heart rate?? so i really want to keep pain in there so I think I'm going to take the change and keep it. if I'm going to stay true to what i found and seen right? :) Her creatinine was 0.4 low per hospitals range. and potassium 3.4 low for hospital range. everything else in electrolytes normal. so creatinine being low would indicated decreased muscle mass possibly due to debilitating disease? her vanco levels were normal. pt/ptt normal. her list of meds metoprolol (lopressor) and thats a beta blocker. so its to decrease heart rate and pulse. Fondaparinux (Arixtra) and anticoagulant. vitamins, tylenol, zofran, morphine she was on other meds previously but these were her orders the last 3 days. So what do you think of these?

Impaired comfort related to increased physical therapy due to contractures as evidence by facial mask of pain; grimacing and crying.

Constipation related to pain medication as evidence by hard firm stool

Impaired skin integrity related to physical immobility as evidence by stage 1 ulcer on the back of head.

Impaired physical mobility related to loss of consciousness (axonal brain injury), and cognitive impairment as evidence by inability to reposition herself, limited range of motion, and bilateral contractures of hands.

Self-Care Deficit, Bathing Hygiene related to neurological deficit as evidence by patient being bed bound, GCS of 6T.

Interrupted family processes related to unresponsiveness of patient, unpredictability of outcome, prolonged recovery period, and the patient's residual physical disability as evidence by mother sleeps in car at hospital and goes home to care for self and other 4 children twice a week.

Its so late! This is due the 15th, but I want to do my care plan in stages :). its my first one :). Thank you so much for your input. Please if you have any suggestions on the above let me know

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

https://allnurses.com/nursing-student-assistance/desperately-need-help-170689.html

https://allnurses.com/general-nursing-student/help-w-head-198146.html

care plan basics:

every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

how does a doctor diagnose? he/she does (hopefully) a thorough medical history and physical examination first. surprise! we do that too! it's part of step #1 of the nursing process. only then, does he use "medical decision making" to ferret out the symptoms the patient is having and determine which medical diagnosis applies in that particular case. each medical diagnosis has a defined list of symptoms that the patient's illness must match. another surprise! we do that too! we call it "critical thinking and it's part of step #2 of the nursing process. the nanda taxonomy lists the symptoms that go with each nursing diagnosis.

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories.

https://allnurses.com/general-nursing-student/help-care-plans-286986.html

the following afre care plan examples with some particular to you diagnosis......they are very good!!!!

http://wps.prenhall.com/chet_perrin_criticalcare_1/98/25166/6442679.cw/index.html

http://wps.prenhall.com/chet_perrin_criticalcare_1/98/25166/6442499.cw/index.html

http://www.csufresno.edu/nursingstudents/fsnc/nursingcareplans.htm

http://www.pterrywave.com/nursing/care%20plans/nursing%20care%20plans%20toc.aspx

http://www.snjourney.com/clinicalinfo/careplans/careplann.htm#ngdx

http://www.delmarlearning.com/companions/content/0766822257/apps/appc.pdf

http://www.delmarlearning.com/companions/content/0766822257/apps/appa.pdf

all of the above are care plan templates with nursing diagnosis's and rationale so you can use them as guidelines to help you.

http://www.indstate.edu/search/results.htm?cx=009518751984494415591%3a_syjfg8ny3a&ie=utf-8&q=nursing+care+plan&sa.x=0&sa.y=0 click on how to use this workbook. in it is a printable template that will help you immensely

powerpoints:

chapter 12: assessing

chapter 13: diagnosing

chapter 14: outcome identification and planning

chapter 15: implementing

chapter 16: evaluating

i hope this helps:d

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i got asked to look in on this thread to see if i could add anything. just one thing to this student first:

:yeah::yeah::yeah::yeah:brava!!!!:yeah::yeah::yeah::yeah:

great job in thinking and assessing and looking up rationales.

and of course she has pain. think you'd have pain if half your face was stove in and fractured and you had a pressure ulcer on the back of your head (where's the silicone pad?). not to mention the rest of it...

tylenol is pretty decent for ortho pain, so maybe giving that round the clock for pain and see if she can need less mso4. if she has been getting mso4 for weeks she may have some withdrawal symptoms-- watch for that.

you might also see if they can give her tube feeds with extra fiber, or add metamucil/psyllium with a lot of extra water for the constipation, or some other otc fiber preparation.

beta blockers not only lower heart rate, they prevent the heart from responding to adrenalin by increasing heart rate and bp. so it's useless to look at bp/heart rate as an indicator for pain. other meds are pretty standard, but at this point should mostly be transitioned to oral/tube feed to decrease risk of infx from iv access.

risk for infx r/t trach, loss of normal airway protection, bedrest, possible aspiration-- watch those secretion for color changes, wbc, fever, position changes to decrease pooling/atelectasis. do they still put a teeny bit of blue food coloring in tube feedings (not methylene blue) so you can see they're staying where they belong? try that, it's a nursing intervention (doesn't need to be part of a physician plan of care).

good spot on the mom, too. you might also look at grief/grieving.

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Re: pain meds.

Can this patient 'blink'? Using a blink once for yes, twice for no can be a lot more useful than it sounds at first:up:.... if she's got tears, she's "in there" (tracking also a clue).

I'd just ask her, with the blink instructions....the worst thing that happens with that are 'crickets'.... the best is that she communicates what's going on. See if ST has any ideas :)

With the pain meds- careful documentation of pre/post pain med neuro checks is really important. Also, think about what pain meds do to the gut- and what intra-abdominal pressure does to ICP. What could help that?

Also, talk to her about general things when you're doing care. What's going on with some superficial stuff (weather, sports,) see if the family can give some info about her interests...not feeling like an object can decrease stress :)

See what the verdict is this decade on hand rolls to help prevent further contractors- and see if PT/OT is working on these- some may be myoclonic activity from the head injury.

Simple things can help anxiety- and that can help with pain as well. If she seems like she's in pain - and the stuff is ordered, I'd give it- unless she says no, via some form of communicating :)

AND, yeah- you did a really good job :)

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Thank you all so much!!! i turned in my care plan...and incorporated your advice during my care of the patient. she is on her way to rehab. I appreciate all of your input. this is my first semester, first care plan, and first experience on all nurses.com. very pleasant. thank you again for your great advice!!!! :redbeathe:redbeathe

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Very few who ask for help do the work you did....nor do they say thank you!!!!

You are very welcome!! anytime!!! Well done!!! You did the work we just guided you! :)

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