r/t brain trauma?

Double-Helix, BSN, RN · Jul 29, 2012

You can be more specific than cerebrovascular impairment- which could be anything from a concussion to a bleed to a lobectomy.

Think about what happens to the brain when a stroke (due to a thrombus) occurs. A clot blocks the blood vessel in the brain, which cuts off the flow of blood and oxygen and nutrients to that area of the brain. As a result, the tissues and nerves are permanently injured or die.

What's the medical term used for injury or death to tissues caused by lack of blood flow? _________?

When the brain tissue dies, it can no longer correctly conduct electrical impulses from one area of the brain to another, or from one area of the brain to the body.

So your diagnosis would be Acute Confusion r/t ineffective conduction of neural impulses secondary to _______ brain tissue injury.

GeauxNursing · Jul 29, 2012

Awesome. I appreciate the in depth answer, but that is too complicated for my needs. Really I just want to know if I'd say brain trauma instead of stroke. I need to be semantically correct.

Double-Helix, BSN, RN · Jul 30, 2012

In that case, no, you should not use a medical diagnosis as your r/t.

You should, however, use an accurate r/t and "trauma" doesn't accurately describe the pathophysiology of a stroke. I'm rather curious as to why you're more concerned with semantics than the accuracy of your care plan.

firstinfamily, RN · Jul 30, 2012

I believe the more appropriate term would be "brain injury" instead of "brain trauma". When I read trauma I think of something that was related more to a MVA or blunt trauma type of injury. However, brain injury covers a broad topic and it is not a "Medical diagnosis" Also, some of the short-term memory difficulty may return after the edema in the brain has lessened. Keep stimulating your patient!!!! Keep asking them questions that would use short-term memory, stimulate those neurons!!

nurseprnRN, BSN, RN · Jul 30, 2012

wrong, but a common mistake, and you can tell your instructor it's in the nanda-i 2012-2014, the definitive, authoritative work on nursing diagnosis. defining characteristics (which is, when you get down to it, a much more useful term than "related to") can certainly include a medical diagnosis. as an example, which i pulled by opening my book at random:

fatigue: an overwhelming sustained state of exhaustion and decreased capacity for physical and mental work at the usual level.

related factors (in part-- it's a long list) anxiety, depression, anemia, disease states, malnutrition (all of these are medical diagnoses)

the reason your faculty don't want you to use a medical diagnosis alone is because so many people think that nursing diagnosis is entirely dependent on medical diagnosis, and that makes people lazy (because they don't do their own assessment) and devalues the power of nursing as its own specialty with assessment powers.

so, if your patient is acutely confused, there may be other factors at work besides her cva. what might those be? are you sure that the cva is the only thing at fault? i'm looking at the nanda-i for acute confusion: abrupt onset of reversible disturbances of consciousness, attention, cognition, and perception that develop over a short period of time. is this what happened to your patient? this diagnosis includes related factors of delirium, dementia, fluctuation in sleep-wake cycle (cva can certainly cause this if it damages the limbic system), age >60, substance abuse. look up the rest of it and see if it really applies to your patient by your assessment data.

Katie71275 · Jul 30, 2012

How many dx do you have to use? Im curious if you are using Confusion as your top 1? I don't see that being the top priority with a CVA pt.