Traumatic Brain Injury Nursing Diagnosis and Nursing Care Plan

Traumatic Brain Injury Nursing Care Plans Diagnosis and Interventions

Traumatic Brain Injury NCLEX Review and Nursing Care Plans

Traumatic Brain Injury (TBI) is caused by a sudden external force that can be penetrating or blunt trauma to the head. The area of damage can be in one area of the brain (focal) or more than one area of the brain (diffuse).

The severity of damage can range from a mild concussion to life-threatening coma or death.

Signs and Symptoms of Traumatic Brain Injury

The signs and symptoms  of TBI vary from mild to severe and may appear immediately or days later depending on the type of injury.

  1. Mild TBI
    • headache
    • dizziness or loss of balance
    • nausea and/or vomiting
    • fatigue or drowsiness
    • blurring of vision or sensitivity to light
    • ringing in the ears or sensitivity to sound
    • changes in sleeping pattern
  2. Moderate to severe TBI
    • loss of consciousness
    • seizures or convulsion
    • CSF leaking from the nose or ears
    • dilation of the pupils
    • loss of sensation or muscle coordination

Causes of Traumatic Brain Injury

There are various events that can cause structural damage affecting the whole physiological process of the brain and body. Traumatic brain injury can be caused by the following events:

  • Falls. Accidental falls from higher surfaces or slipping on the floor can cause a severe blow to the head. This is the most common cause of mild traumatic brain injury among children and old-age adults.
  • Motor vehicle accidents (MVAs). Car collisions and even pedestrians can be involved in such accidents which is the most frequent type of trauma among males and young adults. This is also the leading cause of TBI-related death.
  • Violence. This includes assault, domestic violence, child abuse, or shaken baby syndrome which is caused by violent shaking. Young adult males with chronic alcohol abuse are most likely to sustain and cause violence-related TBI.
  • Sports injury. Contact sports increase the risk of falls and collisions with objects or other players. Recreational activities like hiking, skiing, biking, rafting, and boating also increase the risk for TBI-related injuries. These are common among youths and active young adults.
  • Blast injuries. This happens during an explosion where the shock wave causes increased pressure in the brain including blood vessel rupture, impaired perfusion, and oxygenation to the brain. This is common among military personnel.
  • Penetrating injury. Happens when there is a break in the skull, or an object penetrates the skull such as a gunshot wound or being hit by a baseball bat causing bone fragments to penetrate the skull.

Risk Factors to Traumatic Brain Injury

Increase risks are seen in certain age groups and events such as:

  • Children age 4 and below have an increased risk for falls because of their underdeveloped body and difficulty with coordination and balance. Another factor is that they cannot anticipate the danger and damage it may cause.
  • Adults 60 and older also have a high incidence of accidental falls. Restrictions in mobility from degenerative diseases, physical and sensory disabilities and comorbidities are the factors that may predispose them to traumatic brain injury.
  • Male patients represent almost 80% of all reported TBI accidents yearly, although incidence lessens with ages 75 and above. Male patients are commonly involved in vehicular accidents, sports-related injuries, and military service explaining the increased incident rate.
  • Athletes especially those in contact sports and match play increase the risk for TBI with severity varying by position played, age, and duration of involvement in the game. Increasing engagement in recreational activities or adventurous activities without proper training increases the risk of sustaining an injury. These two represent 20% of all TBI among adolescents and young adults.
  • Young adult males with chronic alcohol abuse or mental health instability have an increased risk of sustaining traumatic brain injury from violence-related incidents.
  • Young women and children are the most vulnerable age group usually involved in an abusive environment. There are fewer reported cases of this due to their vulnerability and fear as this may also be related to chronic alcohol abuse, drug abuse, or mental health problem.

Complications of Traumatic Brain Injury

There are acute and chronic changes with short-term and long-term debilitating effects on the different body functions such as:

  • Altered level of consciousness. The patient’s state of consciousness may vary and improve over time depending on the prognosis and severity of the brain damage.
    • Minimally conscious state with periods of awareness about the environment and response to stimuli.
    • Vegetative state is also called unresponsive wakefulness syndrome where the patient is unconscious with periods of wakefulness.
    • Coma patients cannot respond to stimuli and do not show any signs of wakefulness.
    • Brain death is considered irreversible without any signs of brain functions.
  • Physical complications. These conditions can be prolonged or permanent depending on the affected part of the brain.
    • Headaches are common and may occur persistently.
    • Vertigo or dizziness.
    • Tremors and seizures are also called post-traumatic epilepsy with recurrent episodes.
    • Hydrocephalus.
    • Brain bleed or infections are common in penetrating injuries where the bacteria can enter the wounds.
    • Blood vessel damage can lead to blood clots or stroke.
    • Paralysis or muscle weakness.
  • Cognitive problems such as altered awareness, memory, learning, reasoning, judgment, and concentration.
  • Communication problems such as difficulty speaking, reading, and writing.
  • Behavioural and emotional changes such as irritability, disinhibition, anxiety, depression, and post-traumatic stress disorder (PTSD).
  • Sensory problems such as altered sense of smell or taste, swallowing problems, hearing, and vision changes.
  • Degenerative brain disease such as Alzheimer’s disease or dementia which may occur later in life.

Diagnosis of Traumatic Brain Injury

  • Neurological examination. A quick and complete neurological examination will be done using the Glasgow Coma Scale (GCS), a clinical tool designed to assess the severity of sustained TBI using a scoring system. A Neurologist may also check the patient cognitive function by checking for memory loss or awareness. Motor functions such as reflexes, balance, and coordination together with sensory functions such as hearing and vision will also be assessed to complete this examination.
  • Patient history. This is essential to determine the extent of the injury. Ask the patient or significant others about the type of injury sustained, mechanism of injury, loss of consciousness and duration, or any physical or mental changes. It is important to verify the data with significant others or witnesses for accuracy and to check for memory loss.
  • Imaging. It is the most accurate diagnostic procedure to picture the extent of the injury:
    • CT Scan. Quickly detects the presence of bleeding, blood clots, swelling, and fractures in the brain.
    • MRI. Commonly use once the patient has stabilized to determine changes in the brain structure and function or microhemorrhages that are not seen on a CT scan.
    • X-ray. A plain x-ray of the skull is recommended for patients with mild neurological dysfunction only.
  • Blood test. These blood-based biomarkers measure the level of certain proteins released in the bloodstream within 12 hours of head injury called the Banyan Brain Trauma Indicator.
  • Intracranial pressure monitoring. This is done using a probe inserted through the skull to monitor the pressure in the brain.

Treatment for Traumatic Brain Injury

Treatment depends on the severity and extent of the injury. Patients with mild to moderate TBIs often need complete rest and gradual resumption of activities. For those with moderate to severe TBI, treatment focuses on stabilizing the patient to prevent further damage such as:

  1. Medications. This prevents secondary damage to the brain by controlling the symptoms of TBI and the risk associated with it.
    • Anticonvulsant. Seizures are common after a brain injury and may cause further damage. May be given continuously if seizures occur.
    • Anti-anxiety. This can help in aiding feelings of anxiousness and fear.
    • Anticoagulants. To prevent blood clots that can cause secondary injury.
    • Antidepressants. This treats symptoms of depression and mood swings.
    • Diuretics. Prevents the accumulation of excess fluid in brain tissue reducing the intracranial pressure.
    • Muscle relaxants. To reduce muscle spasms and relax constricted muscles.
    • Stimulants. Help maintain alertness and attention.
  2.  Surgery. Emergency surgery is done once the patient has stabilized to reduce further damage by:
    • Removing blood clots. Blood can pool in the brain and can lead to blood clots putting pressure on the brain.
    • Repairing skull fractures. Removing and setting skull debris can start the healing process of the surrounding tissue.
    • Relieving intracranial pressure. A shunt is placed to drain the excess fluid in the brain caused by swelling or blood pooling.
  3. Therapy. Rehabilitation therapy includes different types of professionals and specialists, family, and support systems that will help the patient recover and regain functions as normal as possible, this includes:
    • Physical therapy. To regain physical strength, mobility, and coordination.
    • Occupational therapy. Relearn activities of daily living.
    • Speech therapy. Improve communication and use of assistive communication devices.
    • Psychological counselling. Improve general well-being by learning coping skills with the help of medications.
    • Cognitive therapy. Improve memory, judgment, perception, and attention.

Nursing Diagnosis for Traumatic Brain Injury

Nursing Care Plan for Traumatic Brain Injury 1

Decreased Intracranial Adaptive Capacity

Nursing Diagnosis: Decreased Intracranial Adaptive Capacity secondary to traumatic brain injury related to injury with cerebral edema as evidenced by increase of more than 10 mm Hg in intracranial pressure (ICP).

Desired Outcome: The patient will be able to exhibit and maintain optimal cerebral tissue perfusion with ICP measurement of less than 10 mm Hg.

Traumatic Brain Injury Nursing InterventionsRationale
Evaluate the patient’s Glasgow Coma Scale or GCS score, including the pupil size, and reaction to light and stimulus.The Glasgow coma score is the most reliable tool for assessing the patient’s neurologic status. Any decrease in the score of 15 (the highest score) would suggest cerebral ischemia. It would also mean a sign of increased ICP.
Evaluate for the presence of rhinorrhoea, otorrhea, ecchymosis on top of the mastoid process (Battle’s sign), and periorbital ecchymosis (Raccoon eyes).The mentioned clinical manifestations are suggestive of a skull fracture, either in the frontal, orbital, or basal part.
Evaluate for protective reflexes like swallowing, coughing, and gagging.Absence or loss of these reflexes may indicate worsening brain trauma and increased risk of aspiration.
Elevate the head of the bed to low Fowler’s position (about 30 degrees). Ensure to keep the patient’s head in a neutral position.Maintaining the patient’s head in this position would help in the cranial venous blood flow that eventually will decrease the ICP, thus improving the patient’s consciousness.
Educate the patient and the caregivers to limit Valsalva maneuver.Valsalva maneuver, such as straining or coughing, will cause elevated intrathoracic pressure that will consequently increase the patient’s ICP.
Ensure to provide hyperventilation to the patient before any suctioning of the patient’s trachea.Hyperventilation and pre-oxygenation prior to the suctioning of the patient can prevent hypoxemia, hypercapnia, and hypotension that can elevate the ICP.

Nursing Care Plan for Traumatic Brain Injury 2

Risk for Electrolyte Imbalance

Nursing Diagnosis: Risk for Electrolyte Imbalance secondary to traumatic brain injury related to disturbances in the regulatory mechanism resulting in elevated anti-diuretic hormone (ADH) as evidenced by weight increases, and presence of edema.

Desired Outcome: The patient will be able to exhibit a reduction of weight to normal, elevations in urine output of at least 30 ml/hr, and maintenance of blood pressure within the baseline.

Traumatic Brain Injury Nursing InterventionsRationale
Take note of the patient’s sodium levels and weight. Inform immediately the physician of any significant findings.Sodium is an essential component and the electrolyte in the maintenance of different body processes, especially in the fluid and electrolyte equilibrium. In the instance of a traumatic brain injury, the mechanism of electrolyte balance can be compromised, thus affecting the control and use of sodium. This may present as a syndrome of inappropriate anti-diuretic syndrome (SIADH), wherein the body concentrates urine improperly resulting in disproportionate water retention. The standard sodium level in the blood is 135 to 145 mEq/L. Levels of 118 mEq/L and below may cause seizures.
Evaluate the patient for the presence of fingerprint edema on the chest, particularly the sternum.Fingerprint edema is a phenomenon observed when the patient’s skin is pressed to assess for edema but leaves a “fingerprint” mark on the area. It is also called pitting edema. The presence of fingerprint edema signifies cellular edema in the body.
Anticipate regulation of the patient’s fluid intake within 500 to 1000 ml per 24 hours.Implementing fluid restriction will help to achieve equilibrium on the electrolytes and fluids in the body by restraining unnecessary build-up that can further compromise the patient.
Ensure that the patient’s head of the bed is elevated to at least 10 to 20 degrees, especially in the presence of hypervolemia.This positioning of the head will promote cerebral venous return and drainage of excess fluids in the brain. Furthermore, this position reduces the release of the anti-diuretic hormone that can compound the current state of the patient.
Anticipate specimen collection of the patient’s blood and urine to check for electrolyte levels, particularly sodium levels.Routine assessment of the patient’s electrolytes will help with the monitoring of the patient’s improvement and the evaluation of the progress and effectiveness of the rendered treatment.

Nursing Care Plan for Traumatic Brain Injury 3

Risk for Seizures

Nursing Diagnosis: Risk for Seizures secondary to traumatic brain injury related to intracranial bleeding and hypoxia.

Desired Outcomes:

  • The patient will be free from harm due to seizure activity.
  • The patient will not exhibit any seizure activity within the shift.
Traumatic Brain Injury Nursing InterventionsRationale
Assess the patient for the presence of any seizure episodes. Take note and report the following: Time of onsetBody part involvedPresence of incontinenceTonic-clonic statusLength of seizure activityPost-ictal statusIt is found that about 5% of patients who suffered from non-penetrating head trauma would develop seizures during their care. The presence of seizure episodes can cause hypoxia, that if consistent and long enough, may cause cardiopulmonary arrest. Documenting the characteristics of each seizure activity will aid in the assessment of its type and category.
Observe and take note of clinical manifestations of airway compromise.During seizure activity, one of the muscles that relaxes and become uncontrolled is the tongue. Because of this, the tongue may slide back of the patient’s throat and block the airway, thus can lead to obstructive hypoxia.
 Anticipate placing the patient on seizure precautions through the following: Raising bed railsAdjusting the height of the bed to the lowest setting.Putting padding on the bedEnsuring that suction and oxygen supplementation is readily available in the patient’s room.These preparations are necessary in ensuring patient safety and limiting injuries during seizure episodes. Patient safety is on top of the hierarchy when caring for patients at risk for seizures.
Render the prescribed anti-convulsant as ordered by the physician.Anti-convulsant medications are important to be given religiously in order to achieve the desired therapeutic doses and serum levels that will control the patient’s seizures. Because of the narrow therapeutic index of anti-seizure medications, ensuring that the rights of medication administration are followed to promote patient safety and achieve the desired results.
Refrain from trying to manipulate the patient’s mouth, (i.e., forceful opening).Introducing objects on the patient’s mouth during seizure activity may cause aspiration, or further harm such as broken teeth, oral tissue injury, etc.

Nursing Care Plan for Traumatic Brain Injury 4

Risk for Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis:  Risk for Imbalanced Nutrition: Less Than Body Requirements secondary to traumatic brain injury related to facial trauma and impaired level of consciousness

Desired Outcome: The patient will be able to maintain adequate nutrition warranted for proper body functioning as evidenced by no losses in patient body mass index (BMI), and normal vital signs.

Traumatic Brain Injury Nursing InterventionsRationale
Regularly evaluate the patient’s status, particularly the electrolytes, glucose, and protein levels.These laboratory values are relevant in determining the overall health of the patient, including the nutritional state.
Evaluate the patient’s muscle mass and integumentary, specifically the skin color and turgor.The presence of dry, flaky skin and reducing muscle mass is a clear warning of a diminishing nutritional health. Due to this, ensuring adequate nutritional support is one of the priorities for patients with compromised nutrition.
Evaluate the patient’s capability for wound healing, taking note of the rate and quality.Wound healing takes extra calories to facilitate tissue growth and regeneration. Being able to assess the slowness or quickness of wound healing is a clear indication if the body has adequate or deficient nutritional supplementation.
Take the patient’s weight regularly.Fluctuations in the patient’s weight are another factor in determining adequate or inefficient nutritional uptake.
Anticipate tube feeding administration for the patient.Due to the nature and effect of the traumatic brain injury, the patient is prone to various factors that inhibit him from taking nutrition the conventional way. With tube feedings, the patient is ensured that adequate calories are given for recuperation. Patients with head injuries would at least need 2000 kcal/day for proper healing. Other avenues for delivering the required calories can be given through the IV route if tube feedings are contraindicated. IV nutritional supplementation would need a central venous catheter to allow for higher calories to be given and to prevent damage to the peripheral veins.
Ensure that the patient’s head of the bed is maintained at least 30 degrees (i.e., low semi-Fowler’s position).This positioning technique prevents the risk of patient aspiration when being given tube feedings.

Nursing Care Plan for Traumatic Brain Injury 5

Acute Confusion

Nursing Diagnosis: Acute Confusion secondary to traumatic brain injury related to increased intracranial pressure as evidenced by elevated ICP of more than 10 mm Hg and Glasgow coma score of 14 and below.

Desired Outcome: The patient will be able to demonstrate a balanced cognitive state as evidenced by an intact level of consciousness and a score of 15 on the Glasgow coma scale (GCS).

Traumatic Brain Injury Nursing InterventionsRationale
Evaluate the patient’s Glasgow Coma Scale scores as often as ordered by the physician.The Glasgow Coma Scale is a reliable tool in determining the neurological status of the patient. Scores of 14 and below would indicate deviations in the patient’s mentation and would warrant prompt intervention. Likewise, any changes in mental status could indicate elevations in the patient’s ICP.
Ensure that the patient is reoriented by the healthcare provider as often as possible, taking note to include reorientation to person, time, situation, and place.Patients with traumatic brain injury would usually have memory issues. With these, giving out repeated information is warranted to facilitate retention and familiarization with the required data. Also, informing the patient of these data may help reduce anxiety and allow for recuperation of their cognitive health from the baseline.
Ensure that the healthcare provider introduces themselves before rendering any interventions to the patient. Take note to use simple and brief statements before, during, and after the processes.These techniques are portions of the reorientation process for the patient with traumatic brain injury. Utilizing simple and brief statements prevents information overload that may make the confused patient even more confused and irritable.
Encourage assigning the same care staff to care for the patient.Frequent modifications in staffing and patient environment may induce more confusion in the already confused patient. Consistent assignment of familiar staff to the patient and preventing any sudden changes in the patient’s environment would facilitate a conducive atmosphere for recuperation.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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