Traumatic Brain Injury, Unrestrained Driver, 23 Years Old

[jadespirro]

Need a little help, Please....Pt., severe TBI, w/ depressed skull fractures, Cranioectomy, Shunt inplace, Tracheotomy w/ oxygen, PEG, Non-responsive, and pupils fixed and dilated. There is occasional eye opening and occasional arm will lift with no purpose.

I am working on my careplan and I have come up with this:

Risk for aspiration related to absence of protective measures as evidenced by reduced level of consciousness, tracheotomy in place, difficulty in coughing, and dysphagia

Decreased intracranial adaptive capacity related to traumatic head injury as evidenced by continued fluid build up despite intracranial shunt, hemicranioectomy

Am I way off here? This is my second care plan and I am still lost on these diagnosis. What would be the protective measures that are absent? Would it be the cranial nerves that control swallowing?

I am feeling so overwhelmed right now. I need some direction here, am I even on the right track? What other diagnosis can you help me with? Are there any significant to the Trach and PEG? Any help would be greatly appreciated....I love this place. And I have loved going to the hospital and learning. I feel such great pride in what little I do know. I am on my way into a great profession! Thank you for your help...!!!!!:wink2:

[Spatialized]

Just real quickly here's a couple of general diagnoses I came up with...

tissue perfusion, ineffective: cerebral r/t traumatic brain injury, AEB...

nutrition imbalance, risk for: greater or less than body requirements r/t PEG & tube feedings

infection, risk for (pneumonia due to laying in bed)

skin integrity impaired, risk for (see above, watch for decubs)

if they wake up...

confusion, acute

Protective measures would include the swallow/gag reflexes which are controlled by the cranial nerves (several of them), but if the patient is vented and they may be under NMBs/anesthesia to keep the muscles from working against the vent so they would be absent that way as well. Depending on the location of the brain injury would effect different CNs (mid-brain, pons, medulla). Trach and PEG are significant as they are portals for infection, but also to the physiological functions they are supporting...

You have to get the basics covered, i.e. ABCs, Maslow, then get deeper, and as a instructor once told, "stop looking for zebras", (things that aren;t really there, or won't be there). There was a thread awhile back with a really great exposition on care planning, things like ABCs, I & Os, how to watch fluids things like that. Try to search, I think it was in the Student Nurses Forum, but if you can't find it, PM me, I cut and pasted it to add to my collection of study aids...

Cheers,

Tom

...sorry if this is disjointed, it was a very long pair of 12s this weekend...

[jadespirro]

Thanks, Tom

You rock!!!! After twelves this weekend and still willing to help, it means a lot to me. Appreciate the feedback....:kiss