Severe TBI + Care Plan

[Nrsroseintraining]

I am a beginning nursing student and up until this point all of my clinical have been long term care. This week I was thrown into a new world on the brain injury side.

I am to do a care plan before I am able to do my head to toe assessment on my patient( that doesn't make any sense to me, but this is how we are doing it) My patient was diagnosed with severe TBI, right temporoparietal occipital skull fracture with extensive ICH and contusions. Pt has trach, and peg tube, muscle weakness, dysphagia, post traumatic seizure, chronic pain, etc etc etc

I prefer to do my nursing care plan of whatever is top priority.

I know there are many options, but based on the ABC's and this particular pt

I would do my nursing care plan on either ineffective airway clearance, or ineffective breathing pattern, aspiration, along those lines I am struggling trying to pick one that fits because I do not have defining characteristics or supportive evidence.

I have yet to work with anyone on a trach and was wondering what sort of care plans/ nursing diagnosis there was related to trachs. Or if I was forgetting a more important diagnosis.

Thanks

[Esme12, ASN, BSN, RN]

Welcome to AN! The largest online nursing community!

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/care map: ADPIE. From our beloved Daytonite....RIP

1. Assessment (collect data from medical record, do a physical assessment of the patient, assess adls, 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)
   

A Care plan/care map/case study is nothing more than the written documentation of the nursing process you use to solve one or more of a patients nursing problems. These are done in different formats but contain similar information. 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. Tune of the main goals every nursing school wants its RNs to learn by graduation is how to use the nursing process to solve patient problems.

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be a medical disease, a physical condition, a failure to be able to perform ADLs(activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on.......the more the better. You will have to be a detective and always be on the alert and lookout for clues.......at all times. That is within the spirit of step #1 of this whole nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. history can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers. part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing.

The meat of the care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. In order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

Care plan reality: Is actually a shorthand label for the patient problem. The patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition). [thanks daytonite]

What I would suggest you do is to work the nursing process from step

#1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms.

#2. Don't forget to include an assessment of their ability to perform adls (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

#3. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. Did you miss any of the signs and symptoms in the patient? If so, now is the time to add them to your list.

This is all part of preparing to move onto the next step of the process which is

#4. Determining your patients problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

#5. How are all your interventions changing/helping this patient.

You, I and just about everyone we know have been using a form of the scientific process, or nursing process, to solve problems that come up in our daily lives since we were little kids.

For example: As a contributor to AN....Daytonite said best.

You are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. You pull over to the side of the road. "What's wrong?" You're thinking. You look over the dashboard and none of the warning lights are blinking. You decide to get out of the car and take a look at the outside of the vehicle. You start walking around it. Then, you see it..............a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated.

What you have just done is.......

Step #1 of the nursing process--performed an assessment. You determine that you have a flat tire. You have just done.....

Step #2 of the nursing process--made a diagnosis. The little squirrel starts running like crazy in the wheel up in your brain. "What do i do?" You are thinking. You could call AAA. No, you can save the money and do it yourself. You can replace the tire by changing out the flat one with the spare in the trunk. .......Good thing you took that class in how to do simple maintenance and repairs on a car! You have just done.....

Step #3 of the nursing process--planning (developed a goal and intervention). You get the jack and spare tire out of the trunk, roll up your sleeves and get to work. You have just done.....

Step #4 of the nursing process--implementation of the plan. After the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. You begin slowly to test the feel as you drive....... Good....... Everything seems fine. The spare tire seems to be ok and off you go and on your way. You have just done

Step #5 of the nursing process--evaluation (determined if your goal was met).

Does this make more sense? Can you relate to that? That's about as simple as the nursing process can be simplified to... BUT........ you have the follow those 5 steps in that sequence or you will get lost in the woods and lose your focus of what you are trying to accomplish.

Critical thinking involves knowing:

1) the proper sequence of steps in the nursing process

2) the normal anatomy and physiology of the human body

3) how the normal anatomy and physiology are changed by the medical and disease process that are going on

4) the normal medical treatment that the doctor(s) are likely to order to treat 5) the medical and disease process going on

6) the nursing interventions that you have learned for the things that support 7) the medical and disease process that is going on

8) making the connection (this is the critical thinking part) between the disease, the treatment and the nursing interventions and where on the sequence of the nursing process you are

[Esme12, ASN, BSN, RN]

Care plans are all about the assessment of the patient. What the patient needs. They should be placed in priority according to the patients assessment and Maslows Hierarchy of needs.

There are five different levels in Maslow’s hierarchy of needs:

1. Physiological Needs
   These include the most basic needs that are vital to survival, such as the need for water, air, food, and sleep. Maslow believed that these needs are the most basic and instinctive needs in the hierarchy because all needs become secondary until these physiological needs are met.
   
2. Security Needs
   These include needs for safety and security. Security needs are important for survival, but they are not as demanding as the physiological needs. Examples of security needs include a desire for steady employment, health care, safe neighborhoods, and shelter from the environment.
   
3. Social Needs
   These include needs for belonging, love, and affection. Maslow described these needs as less basic than physiological and security needs. Relationships such as friendships, romantic attachments, and families help fulfill this need for companionship and acceptance, as does involvement in social, community, or religious groups.
   
4. Esteem Needs
   After the first three needs have been satisfied, esteem needs becomes increasingly important. These include the need for things that reflect on self-esteem, personal worth, social recognition, and accomplishment.
   
5. Self-actualizing Needs
   This is the highest level of Maslow’s hierarchy of needs. Self-actualizing people are self-aware, concerned with personal growth, less concerned with the opinions of others, and interested fulfilling their potential.
   

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

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. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

[Esme12, ASN, BSN, RN]

Well....that was long winded....now tell me about your patient. What did your assessment reveal to you?

[Nrsroseintraining]

Thats the problem! I wont do my assessment until after I have turned in my care plan!

Its already hard enough making a care plan sometimes, yet alone before you have assess or done any care on your patient...

[Nrsroseintraining]

Im not sure what my instructor is looking for without any subjective or objective data or assessment.

[Esme12, ASN, BSN, RN]

Thats the problem! I wont do my assessment until after I have turned in my care plan!

Its already hard enough making a care plan sometimes, yet alone before you have assess or done any care on your patient...

You have no assessment data at all? man I hate that...what are they thinking....Grrrrrrrr. Ok tell me what you do know....

My patient was diagnosed with severe TBI, right temporoparietal occipital skull fracture with extensive ICH and contusions. Pt has trach, and peg tube, muscle weakness, dysphagia, post traumatic seizure, chronic pain, etc etc etc

Look up traumatic brain injury: Traumatic Brain Injury Information Page: National Institute of Neurological Disorders and Stroke (NINDS)

CDC - Severe Traumatic Brain Injury - Traumatic Brain Injury - Injury Center

Traumatic brain injury Definition - Diseases and Conditions - Mayo Clinic

skull fracture: Head Injury - The University of Chicago Medicine

Skull Fracture: Conditions | UCLA Neurosurgery

Skull Fracture: Conditions | UCLA Neurosurgery

Intracereberal hemorrhage: Cerebral hemorrhage - Wikipedia, the free encyclopedia

Intracerebral hemorrhage (ICH)

what area of the brain it affects and how this may affect the patient: https://www.dartmouth.edu/~dons/part_3/chapter_29.html

http://tulane.edu/som/departments/neurology/programs/clerkship/upload/wch12.pdf

[Esme12, ASN, BSN, RN]

Pt has trach, and peg tube, muscle weakness, dysphagia, post traumatic seizure, chronic pain,

Any other data?

First ABC's so you need to think about the trach and trach care. Dysphagia...again airway choking on secretions, clearly they need complete care. Seizures...safety. Do they have a foley? Did the have a crainiotomy? Are they still on the vent? IV"s that you know of?

What care plan resource do you have?

Here are a few ideas that apply

Ineffective Airway Clearance: trach

Risk for Aspiration: dysphagia

Risk for ineffective Cerebral tissue perfusion: traumatic injury

Impaired verbal Communication: trach

Acute Confusion: head injury

Risk for Falls: muscle weakness

Decreased Intracranial Adaptive Capacity: head injury ICH

Risk for Injury: seizures

Impaired physical Mobility: muscle weakness

Acute Pain: self explanatory

Bathing Self-Care deficit: self explanatory

Impaired Skin Integrity: self explanatory...injury/.surgery

Impaired Swallowing: dysphagia

I hope this helps

[mrsboots87]

That's rough that they want a careplan without your assessment date first. That sounds ridiculous because you need your assessment data to plan care. Its kind of the whole point lol. That sucks. Do you have access to the nurses notes on this patient. Maybe see if you can find recent assessment data that way to help guide you better in what this patient is actually experiencing right now.

[nurseprnRN, BSN, RN]

Yeah, we really hate it when some instructor tells a student (who has no experience) to prepare a plan of care for a patient for whom all they have is a medical diagnosis/es. Your instincts are correct, that's foolish and the absolutely wrong way to diagnose anything. But we also have to tell you that your instructor grades you and so you sorta have to do what s/he says.

Therefore, I recommend getting two books stat. One is the NANDA-I 2012-2014, which has all nursing diagnoses with their approved causes (related factors) and defining characteristics. It's about $29 at Amazon, or $25 for your iPad or Kindle. The other is a great book called NANDA,NOC, and NIC Linkages (Johnson, Bulechek et al.), which will give you some ideas about nursing actions to learn about for various conditions. Worth every penny, but be sure to get the 3rd edition (or a more recent one if available) because they still sell the 2nd ed (2006) and it uses a number of NANDA-I diagnoses that have been discontinued for lack of research support.

And stick around here. Esme and I will help you out. :)