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CRANIOCEREBRAL TRAUMA (ACUTE REHABILITATIVE PHASE

)

Craniocerebral trauma, also called head or brain injury (open or closed), includes skull fractures, brain concussion,
cerebral contusion/laceration, and hemorrhage (subarachnoid, subdural, epidural, intracerebral, brainstem). Primary
injury occurs from a direct or indirect blow to the head, causing acceleration/deceleration of the brain. Secondary brain
injury results from diffuse intracerebral axonal injury, intracranial hypertension, hypoxemia, hypercapnia, or systemic
hypotension. Cerebral concussion is the most common form of head injury.
Consequences of brain injury range from no apparent neurological disturbance to a persistent vegetative state or
death. Therefore, every head injury must be considered potentially dangerous.

CARE SETTING
This plan of care focuses on acute care and acute inpatient rehabilitation. Brain injury care for those experiencing
moderate to severe trauma progresses along a continuum of care, beginning with acute inpatient hospital care and
inpatient rehabilitation to subacute and outpatient rehabilitation, as well as home- and community-based services.

RELATED CONCERNS
Cerebrovascular accident (CVA)/stroke
Psychosocial aspects of care
Seizure disorders/epilepsy
Surgical intervention
Thrombophlebitis: deep vein thrombosis
Total nutritional support: parenteral/enteral feeding
Upper gastrointestinal/esophageal bleeding

Patient Assessment Database
Data depend on type, location, and severity of injury and may be complicated by additional injury to other vital organs.

ACTIVITY/REST
May report: Weakness, fatigue, clumsiness, loss of balance
May exhibit: Altered consciousness, lethargy
Hemiparesis, quadriparesis
Unsteady gait (ataxia); balance problems
Orthopedic injuries (trauma)
Loss of muscle tone, muscle spasticity

CIRCULATION
May exhibit: Normal or altered BP (hypotension or hypertension)
Changes in heart rate (bradycardia, tachycardia alternating with bradycardia, other
dysrhythmias)

EGO INTEGRITY
May report: Behavior or personality changes (subtle to dramatic)
May exhibit: Anxiety, irritability, delirium, agitation, confusion, depression, impulsivity

ELIMINATION
May exhibit: Bowel/bladder incontinence or dysfunction

FOOD/FLUID
May report: Nausea/vomiting, changes in appetite
May exhibit: Vomiting (may be projectile)
Swallowing problems (coughing, drooling, dysphagia)

NEUROSENSORY

May report: Loss of consciousness, variable levels of awareness, amnesia surrounding trauma events
Vertigo, syncope, tinnitus, hearing loss
Tingling, numbness in extremity
Visual changes, e.g., decreased acuity, diplopia, photophobia, loss of part of visual field
Loss of/changes in senses of taste or smell
May exhibit: Alteration in consciousness from lethargy to coma
Mental status changes (orientation, alertness/responsiveness, attention, concentration,
problem solving, emotional affect/behavior, memory)
Pupillary changes (response to light, symmetry), deviation of eyes, inability to follow
Loss of senses, e.g., taste, smell, hearing
Facial asymmetry
Unequal, weak handgrip
Absent/weak deep tendon reflexes
Apraxia, hemiparesis, quadriparesis
Posturing (decorticate, decerebrate); seizure activity
Heightened sensitivity to touch and movement
Altered sensation to parts of body
Difficulty in understanding self/limbs in relation to environment (proprioception)

PAIN/DISCOMFORT
May report: Headache of variable intensity and location (usually persistent/long-lasting)
May exhibit: Facial grimacing, withdrawal response to painful stimuli, restlessness, moaning

RESPIRATION
May exhibit: Changes in breathing patterns (e.g., periods of apnea alternating with hyperventilation)
Noisy respirations, stridor, choking
Rhonchi, wheezes (possible aspiration)

SAFETY
May report: Recent trauma/accidental injuries
May exhibit: Fractures/dislocations
Impaired vision, visual field disturbances, abnormal eye movements
Skin: Head/facial lacerations, abrasions, discoloration, e.g., raccoon eyes. Battle’s sign
around ears (trauma signs)
Drainage from ears/nose (CSF)
Impaired cognition
Range of motion (ROM) impairment, loss of muscle tone, general strength; paralysis
Fever, instability in internal regulation of body temperature

SOCIAL INTERACTION
May exhibit: Expressive or receptive aphasia, unintelligible speech, repetitive speech, dysarthria,
anomia
Difficulty dealing with noisy environment, interacting with more than one or two
individuals at a time
Changes in role/family structure related to illness/condition

TEACHING/LEARNING
May report: Use of alcohol/other drugs
Discharge plan DRG projected mean length of inpatient stay: 17.1 days (inclusive/multiple care
setting)
considerations: May require assistance with self-care, ambulation, transportation, food preparation,
shopping, treatments, medications, homemaker/maintenance tasks; change in
physical layout of home or placement in living facility other than home
Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

hemorrhage. reasons for balance problems. X-rays: Detect changes in bony structure (fractures).g. hematoma). complications. determining neurologic deficits not explained by CT. evaluating prolonged interval of disturbed consciousness. Identifies space-occupying lesions. 3. otology. and motor/sensory function. Lumbar puncture and CSF analysis: May be performed in patient with suspected or known increased intracranial pressure when CT or MRI is not diagnostic. . and/or eighth cranial nerve dysfunction. shifts of midline structures (bleeding/edema). Promote optimal functioning/return to preinjury level. Maximize cerebral perfusion/function. (These procedures are not in widespread clinical use. 6. Serial EEG: May reveal presence or development of pathological waves. PET/SPECT tomography: Detects changes in metabolic activity in the brain and may be used for differentiation of head injuries. but are more often used for research. defining evidence of previous trauma superimposed on acute trauma. MRI: Uses similar to those of CT scan but more sensitive than CT for detecting cerebral trauma. Family acknowledging reality of situation and involved in recovery program. neurological deficits resolving/stabilized. trauma. Complications prevented or minimized.decreased systemic BP/hypoxia (hypovolemia. 2. Cerebral function improved. Serum anticonvulsant levels: May be done to ensure that therapeutic level is adequate to prevent seizure activity. Provide information about condition/prognosis. ineffective cerebral May be related to Interruption of blood flow by space-occupying lesions (hemorrhage..) Audiometry. and treatment regimen understood and available resources identified. EEG is not generally indicated in the immediate period of emergency response. e. Serum chemistry/electrolytes: May reveal imbalances that contribute to increased intracranial pressure (ICP)/changes in mentation. Prevent/minimize complications. Toxicology screen: Detects drugs that may be responsible for/potentiate loss of consciousness. 2. ABGs: Determines presence of ventilation or oxygenation problems that may exacerbate/increase intracranial pressure. 5. memory loss Changes in motor/sensory responses. metabolic alterations. Condition/prognosis. NURSING DIAGNOSIS: Tissue Perfusion. cerebral edema (localized or generalized response to injury. EEG may help in diagnostic evaluation for seizures. 3. Support coping process and family recovery. skull fractures. brain tissue shift. drug/alcohol overdose). bone fragments. and vestibular function tests: Diagnostic procedures that identify hearing loss. Generally contraindicated in acute trauma. brain tissue shifts secondary to edema. DISCHARGE GOALS 1. Brainstem auditory evoked responses (BAER): Determines levels of cortical and brainstem function. potential complications.CT scan (with/without contrast): Screening image of choice in acute brain injury. 5. cognition. Plan in place to meet needs after discharge. and treatment. If the patient fails to improve. 4. treatment plan. Cerebral angiography: Demonstrates cerebral circulatory anomalies. focal or diffuse encephalopathy. Activities of daily living (ADLs) needs met by self or with assistance of other(s). restlessness Changes in vital signs DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Neurological Status (NOC) Maintain usual/improved level of consciousness. hemorrhage. 4. cardiac dysrhythmias) Possibly evidenced by Altered level of consciousness. evaluation. and resources. NURSING PRIORITIES 1.

Other movements (posturing and abnormal flexion of extremities) usually indicate diffuse cortical damage. hypercapnia. Glasgow Coma Scale during potential for increased ICP and is useful in determining first 48 hr: location. and time. place. and stupor. and best indicates state of consciousness stimulus away) and nonpurposeful (posturing) in the patient whose eyes are closed because of trauma or movement.. pons. e. hypocapnia. e. and potential for neurological signs/symptoms or failure to improve after increased ICP. Monitor/document neurological status frequently and Assesses trends in level of consciousness (LOC) and compare with baseline. Evaluate eye opening. noting Measures overall awareness and ability to respond to purposeful (obeys command. Note: Secondary brain injury can occur as a result of various factors. spontaneous (awake). Purposeful movement can include grimacing or withdrawing from painful stimuli or movements that the patient desires.g. lapsing into sleep when not stimulated.. Absence of spontaneous movement on one side of the body indicates damage to the motor tracts in the opposite cerebral hemisphere. but may appear drowsy or uncooperative. extent. requiring the patient be transferred to critical care for monitoring of ICP and/or surgical intervention. Measures appropriateness of speech and content of oriented to person. Assess motor response to simple commands.g. the rate of cerebral metabolism. Deterioration in for coma/decreased cerebral perfusion. initial insult may reflect decreased intracranial adaptive capacity. disorientation. If minimal damage has occurred in the uses inappropriate words/phrases that make little cerebral cortex. and medulla is manifested by lack of appropriate responses to stimuli. cause Influences choice of interventions. Damage to midbrain. keeps eyes closed (coma). including hypoxemia. Demonstrate stable vital signs and absence of signs of increased ICP. attempts to push external stimuli. Assess verbal response. note whether patient is alert..g. or is confused. patient may be aroused by verbal stimuli sense. and progression/resolution of central nervous system (CNS) damage. . Determines arousal ability/level of consciousness. More extensive damage to the cerebral cortex may be displayed by slow response to commands. opens only to painful stimuli. sitting up. and presence of cerebral edema/hypotension impairing cerebral perfusion. Note limb movement and document right who is aphasic. e. are integrated if patient can both grasp and release the tester’s hand or hold up two fingers on command. Consciousness and involuntary movement and left sides separately. consciousness. ACTIONS/INTERVENTIONS RATIONALE Neurological Monitoring (NIC) Independent Determine factors related to individual situation.

Assess position/movement of eyes. autoregulation may follow local or diffuse cerebrovascular damage. alternating Changes in rate (most often bradycardia) and bradycardia/tachycardia. Altered reflexes reflect injury at level of midbrain or gag. brainstem and have direct implications for patient safety. Hypovolemia/hypotension (associated with multiple trauma) may also result in cerebral ischemia/damage.ACTIONS/INTERVENTIONS RATIONALE Neurological Monitoring (NIC) Independent Monitor vital signs. e.: BP. Absence of cough and gag reflexes reflects damage to medulla.. noting patterns and rhythm. noting size. autoregulation maintains constant cerebral and widening pulse pressure. Stokes respiration. blurred vision. Note presence/absence of reflexes (e. Response to light reflects combined function of optic (II) and oculomotor (III) cranial nerves. depth damage to areas of the brain. Loss of blink reflex suggests damage to the pons and medulla. (Refer to ND: Breathing Pattern. Heart rate/rhythm. insult/increasing ICP and need for further intervention. dysrhythmias may develop. noting whether in Position and movement of eyes help localize area of brain midposition or deviated to side or downward. Note loss of involvement. .. cough. Cheyne. reflecting brainstem pressure/injury in the absence of underlying cardiac disease. equality. Loss of doll’s eyes indicates deterioration in brainstem function and poor prognosis.g. alterations in visual field. shape. other dysrhythmias.g.) Evaluate pupils. Presence of Babinski reflex indicates injury along pyramidal pathways in the brain. abduction of eyes. double vision Visual alterations. including possible respiratory support. Elevating systolic BP accompanied by decreasing diastolic BP (widening pulse pressure) is an ominous sign of increased ICP when accompanied by decreased level of consciousness. Loss of hypotension in multiple trauma patient. blink. risk for ineffective. indicating pressure/injury to the fifth cranial nerve.g. following. concerns and influence choice of interventions. Assess for changes in vision. e. e. have consequent safety perception. An early sign of increased ICP is impaired doll’s eyes (oculocephalic reflex). cranial nerve and are useful in determining whether the brainstem is intact. Respirations. Pupil size/equality is determined by balance between parasympathetic and sympathetic innervation.g. noting bradycardia. which can result from microscopic (diplopia). noting onset of/continuing systolic hypertension Normally. observe for blood flow despite fluctuations in systemic BP.. light Pupil reactions are regulated by the oculomotor (III) reactivity. Irregularities can suggest location of cerebral periods of apnea after hyperventilation. Babinski).

Avoid placing head on and inhibits cerebral venous drainage. which is an integral status of mucous membranes. Maintain head/neck in midline or neutral position. Useful indicators of total body water. The goal is to prevent transient hypoxemia and hypercarbia associated with suctioning. cumulative stimulant effect. voice. which can reduce ICP. Decrease extraneous stimuli and provide comfort Provides calming effect. Limit number and duration of impair cerebral perfusion. Note: Recent research indicates suctioning passes (e. increase ICP. Weigh as indicated. soft response. reduces adverse physiological measures. guarding These nonverbal cues may indicate increasing ICP or behaviors. Mechanical restraints may enhance fight response.g. Reposition patient abdominal pressures. Avoid/limit use of restraints. Alterations may lead to hypovolemia or vascular engorgement. which can further extremities in blankets when hypothermia blanket is used. reflect presence of pain when patient is unable to verbalize complaints. Increased temperature as indicated. back massage. Tight fitting collar/ties can also limit jugular venous collar or tracheostomy ties when used. Monitor I&O. Familiar voices of family/SO appear to have a relaxing effect on many comatose patients. support Turning head to one side compresses the jugular veins with small towel rolls and pillows. quiet environment. moaning. thereby increasing large pillows. straining at These activities increase intrathoracic and intra- stool/bearing down when possible. vomiting. prevent patient from bending knees and pushing heels against mattress to move up in bed. Periodically check position/fit of cervical ICP. part of tissue perfusion. Provide rest periods between care activities and limit Continual activity can increase ICP by producing a duration of procedures. . Investigate increasing restlessness.g. Encourage SO to talk to patient. which can increase ICP. Wrap (especially with fever and shivering). metabolic needs and oxygen consumption occur administer tepid sponge bath in presence of fever. either of which can negatively affect cerebral pressure. and promotes rest to maintain/lower ICP.. Note: Cautious use may be indicated to prevent injury to patient when other measures including medications are ineffective. Hyperventilate/hyperoxygenate patient for 2 min before Prevents hypoxia and associated vasoconstriction that can suctioning bronchial tree. gentle touch. Unrelieved pain can in turn aggravate/potentiate increased ICP. drainage..ACTIONS/INTERVENTIONS RATIONALE Cerebral Perfusion Promotion (NIC) Independent Monitor temperature and regulate environmental Fever may reflect damage to hypothalamus. Cerebral trauma/ischemia can result in diabetes insipidus (DI) or syndrome of inappropriate antiduretic hormone (SIADH). increasing ICP. Help patient avoid/limit coughing. two passes less than 10 sec each). slowly. Note skin turgor. that prophylactic hyperventilation makes little improvement in intracranial pressure. Limit use of blankets. e.

which may increase cerebral vasodilation and blood volume. Indicative of meningeal irritation. increased Seizures can occur as a result of cerebral irritation. decreasing inflammation. Avoid hip flexion greater than 90 cerebral congestion and edema/risk of increased ICP. Observe for seizure activity and protect patient from injury. seizures can further elevate ICP. elevating ICP. restlessness. which can contribute to increased ICP when cerebral edema impairs CSF circulation. mannitol (Osmitrol). Chlorpromazine (Thorazine). reducing cerebral edema and ICP. phenytoin (Dilantin).ACTIONS/INTERVENTIONS RATIONALE Cerebral Perfusion Promotion (NIC) Independent Palpate for bladder distension.. Collaborative Elevate head of bed gradually to 15–30 degrees as Promotes venous drainage from head. Note: Loop diuretics (e. hypoxia. Administer medications as indicated: Diuretics. irritability. or increased ICP. Assess for nuchal rigidity. potentiating elevation urinary drainage if used. negating beneficial effect of elevating head of bed. Lasix) also reduce production of CSF. Administer IV fluids Fluid restriction may be needed to reduce cerebral edema. Reduces hypoxemia. with control device. reducing tissue edema. and ICP. which can increase ICP. brain cells. Anticonvulsant. Monitor ABGs/pulse oximetry. degrees. furosemide Diuretics may be used in acute phase to draw water from (Lasix).g.g. of ICP. Useful in treating posturing and shivering. Restrict fluid intake as indicated. BP. e. Administer supplemental oxygen as indicated. dexamethasone (Decadron). maintain patency of May trigger autonomic responses. e. Steroids. Note: Use and efficacy of steroids continues to be debated in this diagnosis..g. .g. which may occur because of interruption of dura. additionally. Note: Presence of hypotension can compromise cerebral perfusion pressure. Monitor for constipation. minimize fluctuations in vascular load. twitching.. Prophylactic anticonvulsive therapy may be continued for an indeterminate period of time. Note: This drug can lower the seizure threshold or precipitate Dilantin toxicity. and/or development of infection during acute or recovery period of brain injury. thereby reducing tolerated/indicated. May be effective for treating vasogenic edema— methylprednisolone (Medrol).. onset of seizure activity. e. compounding cerebral damage. Determines respiratory sufficiency (presence of hypoxia/acidosis) and indicates therapy needs. Dilantin is the drug of choice for treatment and prevention of seizure activity in immediate posttraumatic period to reduce risk of secondary injury from associated increased ICP.

May be used to control restlessness. if indicated.g. apneustic. e. . or cluster breathing. ACTIONS/INTERVENTIONS RATIONALE Airway Management (NIC) Independent Monitor rate.g... aqueous vasopressin prevent hypovolemia. e.. e. periods of apnea (apneustic. ataxic. combination with Diuril to treat partial neurogenic DI. Indicated for the treatment of diabetes insipidus to desmopressin (DDAVP).] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Respiratory Status: Ventilation (NOC) Maintain a normal/effective respiratory pattern.g. with ABGs/pulse oximetry within patient’s acceptable range. codeine). chlorpropamide (Diabinese). Note breathing Changes may indicate onset of pulmonary complications irregularities. control hemorrhage. Diabinese may be used alone or in (Pitressin). Slow respiration. elevate depressed fractures.. free of cyanosis. Sedatives. diphenhydramine (Benadryl). evacuate hematoma. May be indicated to relieve pain and its negative effect on ICP but should be used with caution to prevent respiratory embarrassment. Craniotomy or trephination (“burr” holes) may be done to remove bone fragments. ataxic.. acetaminophen (Tylenol).g. e.g.. agitation. rhythm. risk for ineffective Risk factors may include Neuromuscular impairment (injury to respiratory center of brain) Perception or cognitive impairment Tracheobronchial obstruction Possibly evidenced by [Not applicable. e. Antipyretics.g. e. Prepare for surgical intervention. and debride necrotic tissue.ACTIONS/INTERVENTIONS RATIONALE Cerebral Perfusion Promotion (NIC) Collaborative Mild analgesics. Antidiuretic hormone replacement. depth of respiration. nonhormonal agents. presence of signs and symptoms establishes an actual diagnosis. or cluster breathing patterns) are signs of brainstem injury and warn of impending respiratory arrest. NURSING DIAGNOSIS: Breathing Pattern. Reduces/controls fever and its deleterious effect on cerebral metabolism/oxygen needs and insensible fluid losses. (common following brain injury) or indicate location/extent of brain involvement.

position on sides as Facilitates lung expansion/ventilation and reduces risk of indicated. these measures are often necessary in acute rehabilitation phase to mobilize and clear lung fields and reduce atelectasis/pulmonary complications.. congestion. Auscultate breath sounds. Encourage deep breathing if patient is conscious. Suction with extreme caution.ACTIONS/INTERVENTIONS RATIONALE Airway Management (NIC) Independent Note competence of gag/swallow reflexes and patient’s Ability to mobilize or clear secretions is important to ability to protect own airway. acid-base balance. may indicate need for artificial airway/intubation. mechanical ventilation may be required. because it can cause or aggravate hypoxia. which produces vasoconstriction. which may wheezes). If respiratory center is depressed. airway obstruction by tongue. Determines respiratory sufficiency. adversely affecting cerebral perfusion. Note: Administration of intratracheal or IV lidocaine 1–2 min before suctioning suppresses cough reflex and minimizes Valsalva maneuver. Although contraindicated in patient with acutely elevated ICP. rhonchi. odor of secretions. limiting impact on ICP. and therapy needs. Collaborative Monitor/graph serial ABGs.g. Deep tracheal suctioning should be done with caution. Loss of swallow or cough reflex indicated. immobile and unable to clear own airway. . and airway obstruction. Suctioning is usually required if patient is comatose or Note character. Insert airway adjunct as airway maintenance. which can lead to excessive coughing and increased ICP. Note: Soft nasopharyngeal airways may be preferred to prevent stimulation of the gag reflex caused by hard oropharyngeal airway. Assist with chest physiotherapy when indicated. pneumonia). Monitor use of respiratory depressant drugs. jeopardize cerebral oxygenation and/or indicate onset of pulmonary infection (common complication of head injury). sedatives. Administer supplemental oxygen. atelectasis.g. Can increase respiratory embarrassment/complications. noting areas of hypoventilation Identifies pulmonary problems such as atelectasis. e.. color. no longer than 10–15 sec. pulse oximetry. Maximizes arterial oxygenation and aids in prevention of cerebral hypoxia. Elevate head of bed as permitted. Review chest x-rays. Prevents/reduces atelectasis. Reveals ventilatory state and signs of developing complications (e. and presence of adventitious sounds (crackles.

function. . NURSING DIAGNOSIS: Sensory Perception. altered thought processes/bizarre thinking Exaggerated emotional responses. answering “yes” or “no” to questions. following simple verbal identifies signs of progress toward improved neurological instructions. mood/affect. e. and personality changes may develop and persist. sensorium. Assess sensory awareness.g. or changes may remain permanently to some degree. Note problems with vision.g. cognitive. person Change in usual response to stimuli Motor incoordination. place. by altered circulation/oxygenation. Demonstrate behaviors/lifestyle changes to compensate for/overcome deficit. All sensory hot/cold. and focusing/tracking with both eyes. Acknowledge changes in ability and presence of residual involvement. alterations in posture. Damage may occur at time of initial injury or develop later because of swelling or bleeding. feeding self with dominant hand. Observe behavioral responses. with changes involving location of body parts. other increased or decreased sensitivity or loss of sensation senses. apathy.. Individual responses may be variable. (Refer to such as emotional lability. perceptual. with gradual normalization of responses. and awareness of motion and systems may be affected. response to touch. following) irritability/frustration. change in behavior pattern DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Cognitive Ability (NOC) Regain/maintain usual level of consciousness and perceptual functioning. inappropriate affect. exist during recovery from brain injury. disturbed. Upper cerebral functions are often the first to be affected ability to speak. transmission and/or integration (neurological trauma or deficit) Possibly evidenced by Disorientation to time. Helps localize areas of cerebral dysfunction. and/or the ability to perceive and respond appropriately to stimuli. Motor. disturbed (specify) May be related to Altered sensory reception. Information is essential to patient safety. thought process. agitation. Document specific changes in abilities. ACTIONS/INTERVENTIONS RATIONALE Reality Orientation (NIC) Independent Evaluate/continually monitor changes in orientation.g. hallucinations. increased ND: Thought Processes. dull/sharp.. e. crying. inability to tell position of body parts (proprioception) Altered communication patterns Visual and auditory distortions Poor concentration. and impulsiveness. hostility.. Documentation of behavior provides information needed for development of structured rehabilitation. e. but commonalities.

and auditory (tapes. especially if vision is impaired. Provides for normal sense of passage of time and sleep/wake pattern.. Avoid physical or emotional isolation of patient. abilities/delayed response pattern. tactile (touch. Document perceptual deficit and compensatory activities on chart and at bedside. quiet voice. e.. Promotes sense of regular basis.. provide Assists patient to differentiate reality in the presence of feedback. assistance Agitation. poor balance. Provide structured therapies. and perceptual skills. Speak in calm. and environment. Reduces fatigue. control/cognitive retraining. and improves sleep.g. protection from hot/sharp objects. body parts are located. deficits potentiate disorientation and anxiety. e. Patient may have limited attention span/understanding Maintain eye contact.g. Provide meaningful stimulation: verbal (talk to patient). coffee). arrange bed. Allow adequate time for communication and performance Reduces frustration associated with altered of activities. Provide patient safety. Ascertain/validate patient’s perceptions. Use short. and these measures can help patient attend to communication. Cognitive dysfunction and/or visual staff. occupational. and procedures. altered perceptions. deficits. Reorient patient frequently to environment. simple sentences. hand stimulation as well as for documenting progress during holding). treatment plan based on the individual’s unique combination of abilities/disabilities with focus on evaluation and functional improvement in physical. prevents exhaustion. oil of clove. Use day/night lighting. visitors). Collaborative Refer to physical. during acute and recovery stages.g. Note: Absence of rapid eye movement (REM) sleep is known to aggravate sensory perception deficits. radio.ACTIONS/INTERVENTIONS RATIONALE Reality Orientation (NIC) Independent Eliminate extraneous noise/stimuli as necessary. and cognitive Interdisciplinary approach can create an integrated therapists. activities. deficits increase risk of patient injury. Schedule adequate rest/uninterrupted sleep periods. television. cognitive retraining. speech. food to take enhancing sense of control. Identify alternative ways of dealing with perceptual Enables patient to progress toward independence. cognitive. Carefully selected sensory input may be useful for coma olfactory (e. and sensory with ambulation. reducing anxiety Provide written schedule for patient to refer to on a associated with the unknown. Promotes consistency and reassurance. impaired judgment. padded side rails. describe where affected neurological deficits. while compensating for advantage of functional vision. . exaggerated emotional responses/confusion associated with sensory overload. Reduces anxiety. personal articles.

reasoning. ACTIONS/INTERVENTIONS RATIONALE Delirium Management (NIC) Independent Assess attention span. abstract. affect processing and retention of information and can compound anxiety. confusion. Provide information about injury process in relationship Loss of internal structure (changes in memory. Participate in therapeutic regimen/cognitive retraining. Maintain consistency in staff assigned to patient. to symptoms. immediate memory Distractibility. Note level of Attention span/ability to attend/concentrate may be anxiety. circumstances. situation. angry responses. Hallucinations or altered interpretation of stimuli may have been present before the head injury or be part of developing sequelae of brain injury. . Structured reality orientation can reduce defensive reactions. psychological conflicts Possibly evidenced by Memory deficit/changes in remote. which both causes and potentiates anxiety. Recognize changes in thinking/behavior. place. reason. personality with current responses. avoid challenging Patient may be totally unaware of injury (amnesic) or of illogical thinking. to the Provides patient with feelings of stability and control of extent possible. problem-solve. and events Impaired ability to make decisions. NURSING DIAGNOSIS: Thought Processes. severely shortened. extent of injury and therefore deny reality of injury. recent. and disorientation. affecting thought processes. Note: SOs often have difficulty accepting and dealing with patient’s aberrant behavior and may require assistance in coping with situation. or conceptualize Personality changes. distractibility. person. Confer with SO to compare past behaviors/preinjury Recovery from head injury includes a phase of agitation. inappropriate social behavior DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Distorted Thought Control (NOC) Maintain/regain usual mentation and reality orientation. and disordered thought sequences/conversation. altered attention span/concentration Disorientation to time. disturbed May be related to Physiological changes. Explain procedures and reinforce and ability to conceptualize) and fear of the unknown explanations given by others. Present reality concisely and brief.

Inform patient/SO that intellectual function. brain-injured patient may become violent or physically/verbally abusive. may help reduce anxiety. recovery may be complete permanent. and confrontations. irrational behavior. . Provide diversional a Can help refocus attention and reduce anxiety to ctivities. and promote continued work of rehabilitation. Listen with regard to patient’s verbalizations in spite of Conveys interest and worth to individual. Maintain realistic expectations of patient’s ability to It is important to maintain an expectation of the ability to control own behavior. remove patient from the Restraints (physical holding. Reduces risk of triggering fight/flight response. and do not necessarily reflect seriousness of patient’s condition. and problem solving..ACTIONS/INTERVENTIONS RATIONALE Delirium Management (NIC) Independent Review necessity of recurrent neurological evaluations. Useful for determining therapeutic interventions for cognitive and neurobehavioral disturbances. and Most brain-injured patients have persistent problems with emotional functioning will gradually improve but that concentration. or residual effects may remain. tell patient others from harm until internal control is regained.” speak in a calm voice. Instruct in relaxation techniques. reducing anxiety and risk of injury. restrain for brief periods of pharmacological) should be used judiciously to avoid time. manageable levels.g. to “stop. Encourage SO to provide current news/family Promotes maintenance of contact with usual events. provide distraction. Reduce provocative stimuli. enhancing reality orientation and normalization of thinking. to information. Avoid leaving patient alone when agitated. Promote socialization within individual limitations. mechanical.g. If brain some effects may persist for months or even be injury was moderate to severe. maintain hope. appropriate interaction with others) may be helpful in relearning internal structure. happenings. comprehend. Reinforcement of positive behaviors (e. Collaborative Refer for neuropsychological evaluation as indicated. remember improve and progress to a higher level of functioning. enhancing self- speech pattern/content. esteem and encouraging continued efforts. Understanding that assessments are done frequently to prevent/limit complications. escalating violent. frightened.. Anxiety can lead to loss of control and escalate to panic. Severely arguments. behavior. e. situation. Support may provide calming effect. negative criticism. memory. Implement measures to control emotional Patient may need help/external control to protect self or outbursts/aggressive behavior if needed.

disruption of cognitive skills. Refer to support groups. footdrop. ACTIONS/INTERVENTIONS RATIONALE Exercise Therapy: Muscle Control (NIC) Independent Review functional ability and reasons for impairment. and counseling/therapy as supporting/sustaining recovery. transfer. bladder and bowel function.g. bedrest. . including bed mobility. memory.ACTIONS/INTERVENTIONS RATIONALE Delirium Management (NIC) Collaborative Coordinate participation in cognitive retraining or Assists patient with learning methods to compensate for rehabilitation program as indicated. Additional long-term assistance may be helpful in social services. Addresses problems in concentration. NURSING DIAGNOSIS: Mobility. Brain Injury Association. sequencing. Regain/maintain optimal position of function. decreased muscle strength/control DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Immobility Consequences: Physiological (NOC) Maintain/increase strength and function of affected and/or compensatory body part(s). needed.. immobilization Possibly evidenced by Inability to purposefully move within the physical environment. and problem solving. judgment. as evidenced by absence of contractures. visiting nurse. limited range of motion. Mobility Level (NOC) Demonstrate techniques/behaviors that enable resumption of activities. This provides an opportunity for safe interaction between patient and naturalistic environments for the purpose of practicing/establishing effective behavioral responses. e. Identifies probable functional impairments and influences choice of interventions.g. ambulation Impaired coordination. Note: New developments in technology and computer software allow for the creation of interactive sensory-motor virtual reality environments.. e. impaired physical May be related to Perceptual or cognitive impairment Decreased strength/endurance Restrictive therapies/safety precautions. Maintain skin integrity.

Pad chair seat with prevents/reduces risk of skin breakdown. and when patient is in wheelchair/recliner. but those in categories 2–4 are at greatest risk. Increase activity and participation in self. Monitor urinary output. . Bed Rest Care (NIC) Position patient to avoid skin/tissue pressure damage. Maintains mobility and function of joints/functional alignment of extremities and reduces venous stasis.ACTIONS/INTERVENTIONS RATIONALE Exercise Therapy: Muscle Control (NIC) Independent Assess degree of immobility. e. Provide/assist with ROM exercises. Provide meticulous skin care. safe.g. Indwelling catheter used during the acute phase of injury Assist with bladder retraining when appropriate. foam or water-filled cushion. massaging with emollients. and make small position and promotes circulation to all areas. Regular turning more normally distributes body weight Turn at regular intervals. incontinence pads. external catheter. artificial tears. moderate assistance/supervision/teaching (2). keep bedding free of of skin excoriation. Promotes circulation and skin elasticity and reduces risk Remove wet linen/clothing. patient should be repositioned frequently. may be needed for an extended period of time before bladder retraining is possible. using a scale to rate The patient may be completely independent (0). Patient may require patches during sleep to protect eyes from trauma if unable to keep eyes closed. extensive assistance/equipment and devices (3). and sandbags can help prevent abnormal hip rotation. Provide eye care.” and T-bar hands.. or be completely dependent on caregivers (4). intermittent catheterization (for residual and complete emptying). bedrolls.. Support head and trunk. feet. may dependence (0–4). and functional posture. wrinkles. Monitor for proper placement of devices and/or sheepskin devices can help prevent footdrop. Use of high-top tennis shoes. e. planned intervals on commode. program. If paralysis or changes between turns. arms and shoulders. Instruct/assist patient with exercise program and use of Lengthy convalescence often follows brain injury. and mobility aids. Use of pillows.g. Protects delicate eye tissues from drying. feet and legs Maintains comfortable. Note color and odor of urine. hips. physical reconditioning is an essential part of the care as tolerated. “space boots. require minimal assistance/equipment (1). Persons in all categories are at risk for injury. limited cognition is present. several methods of continence control may be tried. and assist patient to shift weight at frequent intervals. Once the catheter is removed. Maintain functional body alignment. Handsplints signs of pressure from devices. patch eyes as indicated. are variable and designed to prevent hand deformities and promote optimal function.

risk of urinary tract infections/stone formation and provides other positive effects such as normal stool consistency and optimal skin turgor. regarding neurological and no other contraindicating factors.ACTIONS/INTERVENTIONS RATIONALE Bed Rest Care (NIC) Independent Provide fluids. NURSING DIAGNOSIS: Infection. free of signs of infection. Stimulation of the digital stimulation as indicated. presence of signs and symptoms establishes an actual diagnosis. Upright fiber/bulk/fruit juice to diet as appropriate. Achieve timely wound healing when present. as indicated. Equalizes tissue pressure. redness. forcing fluids decreases cardiac concerns). Sit patient upright on internal rectal sphincter stimulates the bowel to empty commode or stool at regular intervals. Monitor bowel elimination and provide for/assist with a A regular bowel routine requires simple but diligent regular bowel routine. and helps reduce venous stasis to decrease risk of tissue injury. Add automatically if stool is soft enough to do so. within Once past the acute phase of head injury and if patient has individual tolerance (i. Check for impacted stool. therapeutic activities. including 8 oz cranberry juice. and/or ropy veins in calves of legs. enhances circulation. fever. Collaborative Provide air/water mattress. chest pain. Patient is at risk for development of deep vein thrombosis muscle tension. complications. . Useful in determining individual needs. stasis of body fluids Nutritional deficits Suppressed inflammatory response (steroid use) Altered integrity of closed system (CSF leak) Possibly evidenced by [Not applicable.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Immune Status (NOC) Maintain normothermia. use measures to prevent complications. position aids evacuation. Exercise Therapy: Muscle Control (NIC) Refer to physical/occupational therapists as indicated. kinetic therapy as appropriate. requiring prompt Observe for sudden dyspnea. skin warmth.e. respiratory medical evaluation/intervention to prevent serious distress. Inspect for localized tenderness. and assistive devices.. invasive procedures Decreased ciliary action. tachypnea. risk for Risk factors may include Traumatized tissues. broken skin. (DVT) and pulmonary embolus (PE). May be used to reduce risk of deep vein thrombosis associated with bedrest/limited mobility. Apply/monitor use of sequential compression device.

Reduces exposure of “compromised host.g. Encourage deep breathing. swallowing Hypermetabolic state Possibly evidenced by [Not applicable. Note presence of foul Indicators of developing urinary tract infection (UTI) odor.ACTIONS/INTERVENTIONS RATIONALE Infection Protection (NIC) Independent Provide meticulous/asceptic care. aggressive pulmonary toilet. Observe color/clarity of urine. handwashing techniques. secretions to reduce risk of pneumonia.. Note: Postural drainage should be used with caution if risk of increased ICP exists. risk for less than body requirements Risk factors may include Altered ability to ingest nutrients (decreased level of consciousness) Weakness of muscles required for chewing.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Nutritional Status (NOC) Demonstrate maintenance of desired weight/progressive weight gain toward goal. NURSING DIAGNOSIS: Nutrition: imbalanced. Provide perineal care. Experience no signs of malnutrition. atelectasis. changes in mentation. Gram’s stain may be done to verify Obtain specimens as indicated. requiring prompt intervention. Encourage adequate fluid intake. invasive line insertion sites). May indicate developing sepsis requiring further diaphoresis. wounds. Note presence of chills. complications. Early identification of developing infection permits suture lines. Infection Control (NIC) Collaborative Culture/sensitivity. Monitor temperature routinely.” Screen/restrict access of visitors or caregivers with upper respiratory infections (URIs). maintain good First-line defense against nosocomial infections. Enhances mobilization and clearing of pulmonary Observe sputum characteristics. noting drainage prompt intervention and prevention of further characteristics and presence of inflammation. . Observe areas of impaired skin integrity (e. presence of signs and symptoms establishes an actual diagnosis. presence of infection and identify causative organism and appropriate treatment choices. evaluation/intervention. with laboratory values within normal range. infection. Maintain integrity of closed urinary Reduces potential for bacterial growth/ascending drainage system if used.

handle These factors determine choice of feeding because patient secretions.g. swallow. If patient is able to Parenteral/Enteral Feeding. patients. ileus. requiring intervention and alternative method of providing nutrition. and can improve patient cooperation in eating. Enhances digestion and patient’s tolerance of nutrients Divide feedings into small amounts and give frequently. Reduces risk of regurgitation and/or aspiration.. Evaluates effectiveness or need for changes in nutritional Weigh as indicated. soft foods or semiliquid foods may be more easily managed without aspiration. including with feeding and/or use of assistive devices. glucose. gastric aspirant.. Provide for feeding safety.ACTIONS/INTERVENTIONS RATIONALE Nutrition Therapy (NIC) Independent Assess ability to chew. nitrogen balance studies. desired weight. elevate head of bed while eating or during tube feeding. concurrent conditions (trauma. cardiac/metabolic problems). electrolytes. Identifies nutritional deficiencies. noting decreased/absent or GI functioning is usually preserved in brain-injured hyperactive sounds. relaxing environment. paralysis. mechanical problem exists. contractures of hands. Individual strategies/devices may be needed to improve Involve speech/occupational/physical therapists when ability to eat. Encourage SO to bring in food socialization with SO or friends can improve intake and that patient enjoys. IV/tube Tube feedings (nasogastric.. so bowel sounds help in determining response to feeding or development of complications. .. must be protected from aspiration. e. oral feedings with soft foods and thick liquids initially. and Monitor laboratory studies. e. e. impaired swallow reflexes. normalize the life function of eating. Although the recovering patient may require assistance Promote pleasant. e. Choice of route depends on patient needs/capabilities. Consult with dietitian/nutritional support team.g. iron.g.g. Auscultate bowel sounds. Acute/subacute bleeding may occur (Cushing’s ulcer). prealbumin/albumin. transferrin.) swallow. organ function. BUN. Administer feedings by appropriate means. Collaborative Effective resource for identifying caloric/nutrient needs. or parenteral route may be indicated in presence (Refer to CP: Total Nutritional Support: of gastric/intestinal pathology. AST/ALT.. therapy. body size. e. vomitus for blood. mealtime socialization during meals. gastric) may be required feeding. response to nutritional therapy. wired jaws. amino acid profile. depending on age. Check stools. cough.g.

. Reinforce previous explanations about extent of injury. Listen for expressions of helplessness/hopelessness. can decrease anxiety and enhance coping with reality. Do not Because it is not possible to predict the outcome. Joy of survival of victim is replaced by grief/anger at “loss” and necessity of dealing with “new person that family does not know and may not even like. Encourage and allow injured member to progress toward independence.” Prolongation of these feelings may result in depression. Encourage expression of/acknowledge feelings. and prognosis. Provide accurate and blocking can occur because of emotional trauma. Direct energies in a purposeful manner to plan for resolution of crisis. possibility of death. ACTIONS/INTERVENTIONS RATIONALE Family Integrity Promotion (NIC) Independent Note components of family unit. Identify internal and external resources to deal with the situation. it is deny or reassure patient/SO that everything will be all more helpful to assist the person to deal with feelings right. treatment plan. or incapacitation. availability/involvement Defines family resources and identifies areas of need. reduce misconceptions. Encourage expression of concerns about seriousness of Verbalization of fears gets concerns out in the open and condition. interrupted May be related to Situational transition and crisis Uncertainty about outcomes/expectations Possibly evidenced by Difficulty adapting to change or dealing with traumatic experience constructively Family not meeting needs of its members Difficulty accepting or receiving help appropriately Inability to express or to accept feelings of members DESIRED OUTCOMES/EVALUATION CRITERIA—FAMILY WILL: Family Coping (NOC) Begin to express feelings freely and appropriately. As information at current level of understanding/ability to time goes by. about what is happening instead of giving false reassurance. NURSING DIAGNOSIS: Family Processes. of support systems. reinforcement of information can help accept. fear about the unknown/future expectations. Patient/SO are unable to absorb/recall all information.

day care facility. deal with current crisis.. over time and patient’s needs increase with age. Refer to family therapy. part of the rehabilitation. Attention may be so focused on injured member that other members feel isolated/abandoned. Collaborative Include family in rehabilitation team meetings and care Facilitates communication. Recognition and awareness promotes resolution of guilt. visiting nurse.. understanding that ongoing nature of process. enables family to be an integral planning/placement decisions. Despite accurate information. family members. rehabilitation will bring about a cure. then plateau. legal/financial of altered role function. Trained therapists and peer role models may assist family to deal with feelings/reality of situation and provide support for decisions that are made. patient’s early recovery may be rapid.g. resulting in disappointment/frustration. and provides sense of control. emotional lability. expectations may be unrealistic. Demonstrate and encourage use of stress management Helps redirect attention toward revitalizing self to skills. Evaluate/discuss family goals and expectations. Also as family structure changes counselor. way/enhance coping. assumed by others. Support family grieving for “loss” of member. Family may believe that if patient is going to live. inappropriate sexual or aggressive/violent behavior can disrupt family and result in abandonment/divorce.g. this is typical may help members accept/cope with the situation.ACTIONS/INTERVENTIONS RATIONALE Family Integrity Promotion (NIC) Independent Stress importance of continuous open dialogue between Provides opportunity to get feelings out in the open. e.. additional resources/support are often required. e. Identify individual roles and anticipated/perceived Responsibilities/roles may have to be partially or completely changes. Cognitive/personality changes are usually very difficult for family to deal with. relaxation techniques. Decreased impulse control. . support groups. Also.g. whether efforts at May need assistance to focus energies in an effective resolution/problem solving are purposeful or scattered. visualization. Although grief may never be fully resolved and family Acknowledge normality of wide range of feelings and may vacillate among various stages. Identify and encourage use of previously successful Focuses on strengths and reaffirms individual’s ability to coping behaviors. which can further complicate family coping. Assess energy direction. e. Provides assistance with problems that may arise because homemaker service. Identify community resources. Help family recognize needs of all members. which can compromise family growth and unity. anger. breathing exercises. enhance coping ability.

Discuss plans for meeting self-care needs. prognosis. posttraumatic seizures. medication. requiring further evaluation and supportive interventions. Review information regarding injury process and Aids in establishing realistic expectations and promotes aftereffects. Provide written instructions and schedules for activity. Identify signs/symptoms of individual risks. response. which can occur months to years after injury. statement of misconception Inaccurate follow-through of instructions DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT/SO WILL: Knowledge: Disease Process (NOC) Participate in learning process. limitations. Note: Patient may not be emotionally/mentally capable of assimilating information. Verbalize understanding of condition.. prognosis. repetitive dreams/nightmares). and discharge needs May be related to Lack of exposure. NURSING DIAGNOSIS: Knowledge. psychic/emotional numbness. Knowledge: Treatment Regimen (NOC) Verbalize understanding of therapeutic regimen and rationale for actions. important facts. potential complications. needs. potential complications. understanding of current situation and needs. Identify Recommended activities. treatment. Review/reinforce current therapeutic regimen. medication/therapy ways of continuing program after discharge. delayed CSF leak.g. Recognizing developing problems provides opportunity for prompt evaluation and intervention to prevent serious complications. Provides visual reinforcement and reference source after discharge. and follow-through is essential to progression of recovery/prevention of complications. changes in lifestyle. Discuss with patient/SO development of symptoms. Initiate necessary lifestyle changes and/or involvement in rehabilitation program. self-care. ACTIONS/INTERVENTIONS RATIONALE Teaching: Disease Process (NIC) Independent Evaluate capabilities and readiness to learn of both Permits presentation of material based on individual patient and SO. needs have been established on the basis of a coordinated interdisciplinary approach. such as reexperiencing traumatic event (flashbacks. including adoption of self-destructive behaviors. Correctly perform necessary procedures. deficient [Learning Need] regarding condition. Varying levels of assistance may be required/need to be planned based on individual situation. e. headache/chronic pain. unfamiliarity with information/resources Lack of recall/cognitive limitation Possibly evidenced by Request for information. intrusive May indicate occurrence/exacerbation of posttrauma thoughts. .

neurological deficits and/or be able to resume desired/productive lifestyle. inadequate support systems. stress/anxiety. Pain.g. Note: Studies suggest an increased risk of developing Alzheimer’s disease and the possibility of acceleration of the aging process in brain injury survivors. lack of ability to make deliberate/thoughtful judgments. anemia. groups.. the patient may eventually overcome residual vocational therapists.ACTIONS/INTERVENTIONS RATIONALE Teaching: Disease Process (NIC) Independent Identify community resources. Health Maintenance. outpatient home management. SO/families will require continued support to meet these challenges. chronic—head injury. impaired—significant alteration in communication skills.g. personal resources. physical condition/presence of complications. POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patient’s age. perceptual/cognitive impairments. adjustment to lifestyle changes. and life responsibilities) Memory. Refer/reinforce importance of follow-up care by With diligent work (often for several years with these rehabilitation team. head injury support May be needed to provide assistance with physical care. social services. unfamiliarity with neighborhood resources. acute/chronic—tissue injury/neuronal damage. emotional and financial concerns. impaired—neurological disturbances. physical/occupational/speech/ providers). e. home care/visiting nurse. . e. rehabilitation facilities. insufficient finances. ineffective/Home Maintenance.. and programs. fluid/electrolyte imbalances. Confusion. cognitive retrainers.