pt with traumatic brain injury

[kubebe]

pls i need help with picking an appropraite nursing diagnosis for a 6 year old pt involved in an accident, that left him with a traumatic brain injury. pt is on trach, vent and G tube . i came up with risk for ineffective breathing pattern, and risk for apiration. pls i need some inputs. thanks

[roma4204, BSN, RN]

think about how his age might relate to the diagnosis. think outside the box a little bit as well.

[mentalhealthRN]

when in bed always at high risk for impaired skin integrity...

[roser13, ASN, RN]

Try here:

https://allnurses.com/nursing-student/

[ky_grl82]

If he is not in a coma you could do imapaired verbal communication r/t physical barrier (trach/vent) secondary to brain injury.

An important implementation could be to obtain communication equipment such as an electronic device or picture board/picture cards. Another implementation could be to consider the use of a lipreader translator (LRT).

Hope this helps!

[ObtundedRN, BSN, RN]

Do you have a list of all the nursing dx? Go through the list and look at what you think might be appropriate. I like to help students, and I like to help with nursing Dx, but this case is just too easy to come up with them, and you only brought one idea of your own to us...

[LegzRN]

Think about the parents and family. Not exactly the patients, nx dx, but family has much to do with the healing process.

[joprasklpn]

infection, nutrition, skin integrity

[mskate]

skin integrity, nutrition, hydration, aspiration, risk for impaired oxygenation, anything to do with inability to do ADLs...

[Esme12, ASN, BSN, RN]

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/

http://www.cnsonline.org/www/archive/ms/ms-07.html

a couple of good sites

[kubebe]

thankz everyone for the input! i deceided to go with ineffective airway clearance r/t truamatic brain injury. my goals are:

pt will maintain a patant airway as evidenced by clear lung sounds, normal skin color and eupnea by the end of shift.

pt will maintain optimal gas exchange as evidenced by arterial blood gasses (ABGs) within the patient's usual range, alert responsive mental status or no further reduction in mental status, and no signs of respiratory distress by end of shift

[Meriwhen, ASN, BSN, MSN, RN]

In addition to the above excellent ideas, also consider how the TBI is going to affect his ability to learn what you plan to teach him and his family.