Nursing Care Plan Craniocerebral Trauma (Acute Rehabilitative Phase)

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 andinpatient rehabilitation to subacute and outpatient rehabilitation, as well as home- and community-based services.

RELATED CONCERNS

1. Cerebrovascular accident (CVA)/stroke
2. Psychosocial aspects of care
3. Seizure disorders/epilepsy
4. Surgical intervention
5. Thrombophlebitis: deep vein thrombosis
6. Total nutritional support: parenteral/enteral feeding
7. Upper gastrointestinal/esophageal bleeding
8. Patient Assessment Database
9. 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: 

1. Altered consciousness, lethargy
2. Hemiparesis, quadriparesis
3. Unsteady gait (ataxia); balance problems
4. Orthopedic injuries (trauma)
5. Loss of muscle tone, muscle spasticity

CIRCULATION

May exhibit: 

1. Normal or altered BP (hypotension or hypertension)
2. 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: 

1. Vomiting (may be projectile)
2. Swallowing problems (coughing, drooling, dysphagia)

NEUROSENSORY

May report: 

1. Loss of consciousness, variable levels of awareness, amnesia surrounding trauma events
2. Vertigo, syncope, tinnitus, hearing loss
3. Tingling, numbness in extremity
4. Visual changes, e.g., decreased acuity, diplopia, photophobia, loss of part of visual field
5. Loss of/changes in senses of taste or smell

May exhibit: 

1. Alteration in consciousness from lethargy to coma
2. Mental status changes (orientation, alertness/responsiveness, attention, concentration, problem solving, emotional affect/behavior, memory)
3. Pupillary changes (response to light, symmetry), deviation of eyes, inability to follow
4. Loss of senses, e.g., taste, smell, hearing
5. Facial asymmetry
6. Unequal, weak handgrip
7. Absent/weak deep tendon reflexes
8. Apraxia, hemiparesis, quadriparesis
9. Posturing (decorticate, decerebrate); seizure activity
10. Heightened sensitivity to touch and movement
11. Altered sensation to parts of body
12. 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: 

1. Changes in breathing patterns (e.g., periods of apnea alternating with hyperventilation)
2. Noisy respirations, stridor, choking
3. Rhonchi, wheezes (possible aspiration)

SAFETY

May report: 
Recent trauma/accidental injuries

May exhibit: 

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

SOCIAL INTERACTION

May exhibit: 

1. Expressive or receptive aphasia, unintelligible speech, repetitive speech, dysarthria, anomia
2. Difficulty dealing with noisy environment, interacting with more than one or two individuals at a time
3. Changes in role/family structure related to illness/condition

TEACHING/LEARNING

May report: 

1. Use of alcohol/other drugs
2. Discharge plan
3. DRG projected mean length of inpatient stay: 17.1 days (inclusive/multiple care setting)
4. 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
5. Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

1. CT scan (with/without contrast): Screening image of choice in acute brain injury. Identifies space-occupying lesions, hemorrhage, skull fractures, brain tissue shift.
2. MRI: Uses similar to those of CT scan but more sensitive than CT for detecting cerebral trauma, determining neurologic deficits not explained by CT, evaluating prolonged interval of disturbed consciousness, defining evidence of previous trauma superimposed on acute trauma.
3. Cerebral angiography: Demonstrates cerebral circulatory anomalies, e.g., brain tissue shifts secondary to edema, hemorrhage, trauma.
4. Serial EEG: May reveal presence or development of pathological waves. EEG is not generally indicated in the immediate period of emergency response, evaluation, and treatment. If the patient fails to improve, EEG may help in diagnostic evaluation for seizures, focal or diffuse encephalopathy.
5. X-rays: Detect changes in bony structure (fractures), shifts of midline structures (bleeding/edema), bone fragments.
6. Brainstem auditory evoked responses (BAER): Determines levels of cortical and brainstem function.
7. PET/SPECT tomography: Detects changes in metabolic activity in the brain and may be used for differentiation of head injuries. (These procedures are not in widespread clinical use, but are more often used for research.)
8. Audiometry, otology, and vestibular function tests: Diagnostic procedures that identify hearing loss, reasons for balance problems, and/or eighth cranial nerve dysfunction.
9. Lumbar puncture and CSF analysis: May be performed in patient with suspected or known increased intracranial pressure when CT or MRI is not diagnostic. Generally contraindicated in acute trauma.
10. ABGs: Determines presence of ventilation or oxygenation problems that may exacerbate/increase intracranial pressure.
11. Serum chemistry/electrolytes: May reveal imbalances that contribute to increased intracranial pressure (ICP)/changes in mentation.
12. Toxicology screen: Detects drugs that may be responsible for/potentiate loss of consciousness.
13. Serum anticonvulsant levels: May be done to ensure that therapeutic level is adequate to prevent seizure activity.

NURSING PRIORITIES

1. Maximize cerebral perfusion/function.
2. Prevent/minimize complications.
3. Promote optimal functioning/return to preinjury level.
4. Support coping process and family recovery.
5. Provide information about condition/prognosis, potential complications, treatment plan, and resources.

DISCHARGE GOALS

1. Cerebral function improved; neurological deficits resolving/stabilized.
2. Complications prevented or minimized.
3. Activities of daily living (ADLs) needs met by self or with assistance of other(s).
4. Family acknowledging reality of situation and involved in recovery program.
5. Condition/prognosis, complications, and treatment regimen understood and available resources identified.
6. Plan in place to meet needs after discharge.