Table of Contents
Abstract
Traumatic brain injury leads to millions of deaths globally each year. The chances of better outcomes and prognosis for patients diagnosed with TBI increase when the injury is identified at early onset and treatment is initiated. Even with proper assessment, management, and treatment, the effects of TBI can be experienced throughout the life-span and affects not only the individual but also their family and friends. It is vital that nurses increase the knowledge of clients and family members about TBI, its pathophysiology, long-term effects, and possible complications so that the persons affected by TBI – directly or indirectly – can form realistic expectations for recovery and rehabilitation.
Keywords: Traumatic brain injury, treatment, assessment
Traumatic Brain Injury, also known as TBI, occurs when a traumatic event – such as a car accident or head injury – causes damage to the brain. The pathophysiology of such damage is complex and greatly dependent on the severity of the injury, type of damage, location of the trauma, and even the individual’s age. Health care providers categorize TBI based on the Glasgow coma scale; a mild injury is scored between 13 and 15 points, a moderate score is between 9 and 12, and a severe TBI injury is rated as less than 9. Neurochemical and metabolic processes cascade one after the other in a traumatic brain injury and increases the complexity of the injury and the resulting care (Lewis, 2017).
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Patient Profile: Present complaints and Physical Assessment Findings C.G., a 24-year-old African American male, was in the army and recently returned home after spending 15 months in Afghanistan. He presented to an outpatient clinic with complaints of chronic headaches (which he rated as 8 on a 0-10 scale), personality changes, and difficulty sleeping. He and his wife voiced concerns that he may have PTSD. He has frequent headaches in the mornings and whenever he lies down. He has also been depressed since returning home.
He regularly uses tobacco and drinks multiple cups of coffee every day. He has a history of blackouts during heavy combat, but he cannot recall how many times he has lost conciousness. C.G. also became agitated when he was questioned and jumpy whenever he heard loud noises, such as the ringing of a phone. The nurse noted that his heart rate ranged from 100-130 bpm and SBP ranged from 120 – 160 mm Hg. C.G.’s right pupil reacted sluggishly to light while the left pupil reacted briskly, and both constricted to 3 mm.
Interprofessional Collaboration C.G. was referred to a hospital for an ECG, MRI, and CT scan. The radiologist submitted a report that the CT did not show evidence of a skull fracture, hematoma, or hemorrhage. However, cerebral edema was seen with cingulate herniation on the right side. The MRI showed evidence of mild diffuse axonal injury. The ECG strip showed that C.G. was experiencing Paroxysmal Supraventricular Tachycardia (PSVT).
Nursing Care Plan
Based on the results of C.G.’s diagnostic studies, physical assessment, and GCS score of 12-13, the physician diagnosed the client with mild to moderate TBI. Further observation and assessment are needed to understand the underlying cause of the symptoms C.G. presented in the outpatient clinic. The systolic hypertension that C.G. is experiencing can be attributed to stress, and anxiety but it can also be a result of increased intracranial pressure. Similarly, the presence of PSVT in his ECG can be caused by overexertion, stress, or his regular use of tobacco and caffeine. Nursing Diagnosis. The nurse has diagnosed C.G. with ineffective cerebral tissue perfusion, disturbed sensory perception, ineffective coping, deficient knowledge, and self-care deficit (Herdman, 2018).
The ineffective tissue perfusion is related to cerebral edema as evidenced by loss of conciousness, memory loss, and the CT scan. C.G. has disturbed sensory perception related to psychological stress and anxiety as evidenced by changes in behavior patterns and response to stimuli. C.G. and his wife are at risk for ineffective coping related to situational crisis and both have deficient knowledge related to lack of exposure. C.G. is also at risk for self-care deficit related to depression and pain. Planning. To address ineffective cerebral tissue perfusion, the nurse has set a goal to have C.G. maintain his level of consciousness and cognition, have stable vital signs, have no evidence of further deterioration during the course of his stay in the hospital.
The nurse also plans to teach C.G. effective methods to compensate for and overcome his stress and anxiety so as to mitigate instances of decreased sensory perception. To help C.G. and his wife adapt to their situational crisis, his depression and pain, and their lack of knowledge, the nurse plans to open up pathways of communication so that both C.G. and his wife are aware of what has happened and what they can expect in the future. The goal is that both individuals will verbalize understanding of C.G.’s condition, therapeutic regimen – including pharmacological interventions, and possible complications, as well as identify and connect with the community resources available to them. Interventions. Ineffective cerebral tissue perfusion.
The nurse will assess factors that can cause decreased cerebral perfusion or increased ICP by performing frequent neurological assessments. Deterioration in neurological signs is a possible indicator of increased intracranial pressure due to the brain’s decreased adaptive capacity. Frequent assessment is needed because the client can deteriorate quickly (Lewis, 2017).
The nurse will establish a baseline to compare the client’s neurological status with each subsequent assessment to monitor trends in LOC and ICP. If a change occurs, the baseline will help establish a timeline for, and progression of, the damage (Lewis, 2017). The nurse will regularly monitor vital signs, including the blood pressure, the heart rate and rhythm, and the respirations and pattern. Changes in blood pressure occur with vasomotor damage (which can cause hypertension) or circulatory shock, (which can cause hypotension). Bradycardia can occur with brain damage and irregularities in respirations may suggest increasing ICP (Lewis, 2017).
The nurse will position the client with the head in a neutral position and the head of the bed slightly elevated to promote venous drainage and improve cerebral perfusion (Lewis, 2017). Disturbed sensory perception, ineffective coping, deficient knowledge, and self-care deficit. The nurse will observe for behavioral responses such as agitation, hostility, or crying because frustration, agitation, and anger can complicate care.
The nurse will establish communication with C.G. and his wife to reduce anxiety and enhance understanding (Nurses Labs, 2017). The nurse will assess and document pain regularly prior to administering medication using the PQRST mnemonic and assess C.G. perception of the effectiveness of the therapy (Lewis 2017).
The nurse will maintain a supportive but firm attitude and teach the wife to do the same so that C.G. can maintain his self-esteem and independence by caring for himself as much as possible. The nurse will engage both C.G. and his wife in discussion to educate both individuals about TBI, coping strategies, realistic expectation. The nurse will also connect them with a case manager or social worker who can help the couple identify and utilize the resources that are available to them.
The nurse will also help the couple gain a referral for a psychologist or counselor that will help the couple address C.G.’s depression, PTSD, and behavior patterns (Lewis, 2017). Evaluation. The nurse will evaluate whether or not the goals in the plan of care were met or not, how goals can be adapted if changes are need to the plan, and how to address any deterioration or improvements C.G. presents.
It is important that C.G. will maintain a normal CPP, achieve maximal cognitive and sensory function, and be pain free – or at experience pain only at a manageable level of less than 3 or 4 on a scale of 0-10. (Lewis, 2017). Evidence Based Practice Mild TBI is usually diagnosed late because symptoms are usually non-specific and easy to misdiagnose so families and clients usually build up ineffective coping skills or experience denial about the reality of their sitation by the time the official diagnosis is made (Hyatt, 2014).
“After sustaining mTBI, most patients have a rapid postinjury symptom resolution, but a subset experience persistent symptoms that create unique treatment challenges. Finding ways to help the patient and family manage emotional distress and accept enduring changes may be the key to postinjury reintegration.” (Hyatt, 2014) It is interesting to note that mild TBI has also been linked to the development of dementia in aging veterans. More research is needed but a proactive approach may help C.G. prevent or delay the onset of dementia as he gets older (Mechcatie, 2018).
Conclusion
Mild TBI can be filled with challenges that have lifelong effects and implications on the individual who sustains the injury and their family members, caregivers, friends, and other loved ones. affect the patient’s personal life. Many dynamics will change, and it is the job of the nurse to support the client through the change and prepare them and their loved ones for what is to come.
References
- Herdman, T. H. (Ed.). (2018). NANDA nursing diagnosis list 2018-2020. New York, NY: Thieme Medical.
- Hyatt, K. S. (2014). CE: Mild Traumatic Brain Injury. AJN, American Journal of Nursing, 114(11), 36-42. doi:10.1097/01.naj.0000456426.79527.9b
- Lewis, S. M., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing: Assessment and management of clinical problems (10th ed.). St. Louis, MO: Elsevier.
- Mechcatie, E. (2018). Study of U.S. Veterans Links Mild Traumatic Brain Injury to Dementia Risk. AJN, American Journal of Nursing, 118(8), 16. doi:10.1097/01.naj.0000544150.68455.84 8
- Cerebrovascular Accident (Stroke) Nursing Care Plans. (2017, September 21). Retrieved from nurseslabs.com/8-cerebrovascular-accident-stroke-nursing-care-plans/4/
