What Are the Key Considerations for a Traumatic Brain Injury Nursing Care Plan?

Traumatic brain injuries (TBIs) are a severe form of head trauma that results in brain damage caused by an external mechanical force. This condition may cause temporary or permanent impairment of sensory perception, cognition, mobility, and psychosocial major functions.

TBI is caused by falls, motor vehicle accidents, and head injuries that cause a blow to your head. This condition can be classified as mild or moderate, causing a temporary change in consciousness (loss of consciousness), or severe, causing unresponsiveness or death.

TBI damages are classified as either primary or secondary. Direct injury refers to the immediate effects of the initial trauma on the brain and skull. As a health care provider, secondary injury results from pathophysiological and dysfunctional changes in the brain tissue that occur hours or days later. These include infection, increased intracranial tension, and hypoxemia.

Traumatic Brain Injury Nursing Care Plan

Ineffective Cerebral Perfusion

TBI patients are more susceptible to a reduction in cerebral tissue blood flow. Perfusion can be affected by swelling, bleeding, or CSF leakage as a result of traumatic brain injury. When the brain cannot accommodate more volume changes, it can cause increased ICP. This results in decreased cerebral tissue perfusion and edema. Untreated cerebral edema can cause irreversible brain damage or death.

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Nursing Care Plans Related to Traumatic Brain Injury

Ineffective Cerebral Perfusion

TBI patients are more susceptible to a reduction in cerebral tissue blood flow. Perfusion can be affected by swelling, bleeding, or CSF leakage as a result of traumatic brain injury. When the brain cannot accommodate more volume changes, it can cause increased ICP. This results in decreased cerebral tissue perfusion and edema. Untreated cerebral edema can cause irreversible brain damage or death. Licensed practical nursing schools for nursing programs equip their graduates with essential skills for caring for traumatic brain injury (TBI) patients.

Ineffective Cerebral Perfusion Assessment

1. Assess the patient and get an accurate history. It may be challenging to get an accurate medical history from a patient with a TBI, depending on how severe the injury is. You can get it from the witnesses or first responders. Asking when, where, and how an injury happened is crucial to planning and formulating the best traumatic brain injury nursing care plan.
2. Monitor and assess the neurological status regularly. A change in the level of consciousness may indicate a problem. It is essential to monitor changes in GCS and mental status in patients with TBI because their condition can rapidly deteriorate, requiring emergency surgery.
3. Monitor vital signs

After a TBI, the mechanism of autoregulation is impaired. The cerebral vasculature is damaged by severe TBI, resulting in reduced blood pressure to the brain. The patient may exhibit hypotension or hypertension. Cushing’s triad (irregular breathing, widening pulse pressure, and bradycardia), an early but classic sign of increased ICP, indicates imminent brainstem rupture.

Ineffective Cerebral Perfusion Interventions

1.Monitor the patient’s bilateral responses

In TBI, motor dysfunction often occurs contralaterally to the location of the injury. The motor responses of patients with TBI should be monitored frequently because any deterioration of mobility or abnormal posture could indicate progressive brain damage.

2.Limit the length of treatments and allow rest periods in between

The intracranial pressure can be increased by excessive stimulation and continuous activities.

3.Administer IV fluids

Crystalloid and colloid fluids can support perfusion. Fluids containing dextrose and hypotonic solutions should be avoided. Fluid restriction may be necessary in certain situations.

4.As directed, administer medications

To reduce swelling of the brain, diuretics like mannitol can be prescribed. This helps to improve cerebral blood flow.

5.Prepare for surgery as indicated

The use of a cranial osteotomy can be used to remove bone fragments and elevate fractures that are depressed, control bleeding, evacuate hematomas, debride necrotic tissue, relieve pressure, or control bleeding.

Acute Confusion Care Plan

Mild TBI can cause altered patient cognition, such as acute confusion, impaired reasoning, and decreased memory. Severe TBI can also cause amnesia and prolonged confusion. Registering for an anatomy and physiology course near me is key to understanding the cognitive effects of Traumatic Brain Injuries (TBIs). When pursuing nursing education, ensure the Illinois College of Nursing accreditation has proper comprehensive and quality training accreditation to become a licensed practical nurse.

Acute Confusion Evaluation:

• Test your sensory awareness.
• Examine changes in personality and orientation.
• Assess the level of cognitive impairment in your patient.

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Acute Confusion Nursing Interventions:

• Ensure patient safety.
• Reorientate the patient if necessary.
• Keep your explanations and activities short and simple.
• Eliminate extraneous noise as necessary.
• 5. Offer structured activities and therapies.