Nursing Care Plans for TBI with Examples

Introduction

Traumatic brain injury is when a sudden, external, physical assault damages the brain. It is the most common cause of disability and death in adults. TBI is a broad term that describes a vast array of injuries to the brain. The damage can be focal or diffuse. The severity of an injury can range from a mild concussion to a severe injury that results in a coma or even death.

This blog post discusses nursing care plans for traumatic brain injury(TBI) together with the diagnosis, causes, symptoms and interventions with elaborate examples .As you follow along, remember that our qualified writers are always ready to help in any of your nursing assignments. All you need to do is place an order with us!

Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Signs and Symptoms of TBI

Depending on the type of injury and seriousness of the brain damage, the symptoms of TBI can include:

  1. Headache
  2. Brief loss of consciousness
  3. Dizziness
  4. Confusion
  5. Fatigue or lethargy
  6. Mood changes
  7. Ringing in the ears
  8. Blurred vision or tired eyes
  9. Lightheadedness
  10. Bad taste in the mouth
  11. Change in sleeping pattern
  12. Trouble with memory, concentration, attention, or thinking

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Types of Injuries

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Nursing care plans for tbi with examples 6

Hematoma

Hematoma refers to a blood clot within the brain or on its surface. Hematomas may occur anywhere within the brain. Epidural hematoma is a collection of blood between the dura mater (the brain’s protective covering) and the inside of the skull. Subdural hematoma is a collection of blood between the dura mater and the arachnoid layer, which sits directly on the brain’s surface.

Contusion

A cerebral contusion is bruising of brain tissue. When examined under a microscope, cerebral contusions are comparable to bruises in other parts of the body. They consist of injured or swollen brain areas mixed with blood that has leaked from arteries, veins, or capillaries. Contusions can occur anywhere in the brain, however, contusion at the base of the front parts of the brain is the most common type of contusion.

Intracerebral Hemorrhage

An intracerebral hemorrhage (ICH) describes bleeding within the brain tissue, which may be related to other brain injuries, especially contusions. The size and location of the hemorrhage help determine whether it can be removed surgically.

Subarachnoid Hemorrhage

Subarachnoid hemorrhage (SAH) is caused by bleeding into the subarachnoid space. It appears as diffuse blood spread thinly over the brain’s surface and commonly after TBI. Most cases of SAH associated with head trauma are mild. Hydrocephalus may result from severe traumatic SAH.

Diffuse Injuries

TBIs can produce microscopic changes that do not appear on CT scans and are scattered throughout the brain. This category of injuries, called diffuse brain injury, may occur with or without an associated mass lesion.

Diffuse Axonal Injury

Axonal injury refers to impaired function and gradual loss of axons. These long extensions of nerve cells enable them to communicate with each other. If enough axons are harmed in this way, the ability of nerve cells to communicate with each other and to integrate their function may be lost or significantly impaired, possibly leaving a patient with severe disabilities.

Ischemia

Another type of diffuse injury is ischemia, or insufficient blood supply to certain parts of the brain. A decrease in blood supply to deficient levels may occur commonly in a significant number of TBI patients. This is crucial since a brain that has just undergone a traumatic injury is especially sensitive to slight reductions in blood flow. Changes in blood pressure during the first few days after a head injury can also have an adverse effect.

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Skull Fractures

Linear skull fractures or simple breaks or “cracks” in the skull may accompany TBIs.

Possible forces strong enough to cause a skull fracture may damage the underlying brain. Skull fractures may be alarming if found on a patient evaluation. Fractures at the base of the skull are problematic since they can cause injury to nerves, arteries, or other structures. If the fracture extends into the sinuses, leakage of cerebrospinal fluid (CSF) from the nose or ears may occur. Depressed skull fractures, in which part of the bone presses on or into the brain, can also occur.

Causes of TBI

Traumatic brain injury is usually caused by a blow or other traumatic injury to the head or body. The degree of damage can depend on several factors, including the nature of the injury and the force of impact.

Common events causing traumatic brain injury include the following:

Falls

Falls from a bed or a ladder, downstairs, in the bath, and other falls are the most common cause of traumatic brain injury overall, particularly in older adults and young children.

Vehicle-related collisions

Collisions involving cars, motorcycles, or bicycles — and pedestrians involved in such accidents — are a common cause of traumatic brain injury.

Violence

Gunshot wounds, domestic violence, child abuse, and other assaults are common causes. The shaken baby syndrome is a traumatic brain injury caused by violent shaking in infants.

Sports injuries

Traumatic brain injuries may be caused by injuries from a number of sports, including soccer, boxing, football, baseball, lacrosse, skateboarding, hockey, and other high-impact or extreme sports. These are particularly common in youth.

Explosive blasts and other combat injuries

Explosive blasts are a common cause of traumatic brain injury in active-duty military personnel. Although how the damage occurs isn’t yet well understood, many researchers believe that the pressure wave passing through the brain significantly disrupts brain function.

Risk factors of TBI

The people most at risk of traumatic brain injury include:

  • Children, especially newborns to 4-year-olds
  • Young adults, especially those between ages 15 and 24
  • Adults age 60 and older
  • Males in any age group

Complications of TBI

Several complications can occur immediately or soon after a traumatic brain injury. Severe injuries increase the risk of a more significant number of and more-severe complications.

Altered consciousness

Moderate to severe traumatic brain injury can result in prolonged or permanent changes in a person’s state of consciousness, awareness, or responsiveness. Different states of consciousness include:

Coma – A person in a coma is unconscious, unaware of anything, and unable to respond to any stimulus. This results from widespread damage to all parts of the brain. After a few days to a few weeks, a person may emerge from a coma or enter a vegetative state.

Vegetative state – Widespread damage to the brain can result in a vegetative state. Although the person is unaware of surroundings, he or she may open his or her eyes, make sounds, respond to reflexes, or move.

It’s possible that a vegetative state can become permanent, but often individuals progress to a minimally conscious state.

Minimally conscious state – A minimally conscious state is a condition of severely altered consciousness but with some signs of self-awareness or awareness of one’s environment. It is sometimes a transitional state from a coma or vegetative condition to greater recovery.

Brain death – When there is no measurable activity in the brain and the brainstem, this is called brain death. In a person who has been declared brain dead, removal of breathing devices will result in cessation of breathing and eventual heart failure. Brain death is considered irreversible.

Physical complications

Seizures – Some people with traumatic brain injury will develop seizures. The seizures may occur only in the early stages or years after the injury. Recurrent seizures are called post-traumatic epilepsy.

Fluid buildup in the brain (hydrocephalus) – Cerebrospinal fluid may build up in the spaces in the brain (cerebral ventricles) of some people who have had traumatic brain injuries, causing increased pressure and swelling in the brain.

Infections – Skull fractures or penetrating wounds can tear the layers of protective tissues (meninges) that surround the brain. This can enable bacteria to enter the brain and cause infections. An infection of the meninges (meningitis) could spread to the rest of the nervous system if not treated.

Blood vessel damage – Several small or large blood vessels in the brain may be damaged in a traumatic brain injury. This damage could lead to a stroke, blood clots, or other problems.

Headaches – Frequent headaches are very common after a traumatic brain injury. They may begin within a week after the injury and could persist for as long as several months.

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Vertigo – Many people experience vertigo, a condition characterized by dizziness, after a traumatic brain injury. Sometimes, any or several of these symptoms might linger for a few weeks to a few months after a traumatic brain injury. When a combination of these symptoms lasts for an extended period of time, this is generally referred to as persistent post-concussive symptoms.

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Intellectual problems

Many people who have had a significant brain injury will experience changes in their thinking (cognitive) skills. It may be more difficult to focus and take longer to process your thoughts. Traumatic brain injury can result in problems with many skills, including:

Cognitive problems

  • Memory
  • Learning
  • Reasoning
  • Judgment
  • Attention or concentration

Executive functioning problems

  • Problem-solving
  • Multitasking
  • Organization
  • Planning
  • Decision-making
  • Beginning or completing tasks

Communication problems

Language and communications problems are common following traumatic brain injuries. These problems can cause frustration, conflict, and misunderstanding for people with a traumatic brain injury, as well as family members, friends, and care providers.

Communication problems may include:

  • Difficulty understanding speech or writing
  • Difficulty speaking or writing
  • Inability to organize thoughts and ideas
  • Trouble following and participating in conversations

Degenerative brain diseases

The relationship between degenerative brain diseases and brain injuries is still unclear. But some research suggests that repeated or severe traumatic brain injuries might increase the risk of degenerative brain diseases. But this risk can’t be predicted for an individual — and researchers are still investigating if, why, and how traumatic brain injuries might be related to degenerative brain diseases.

A degenerative brain disorder can cause a gradual loss of brain functions, including:

Alzheimer’s disease, which primarily causes the progressive loss of memory and other thinking skills.

Parkinson’s disease is a progressive condition that causes movement problems, such as tremors, rigidity, and slow movements.

Dementia pugilistica — most often associated with repetitive blows to the head in career boxing — which causes symptoms of dementia and movement problems.

Prevention for TBI

Follow these tips to reduce the risk of brain injury:

  • Seat belts and airbags. Always wear a seat belt in a motor vehicle. A small child should always sit in the back seat of a car secured in a child safety seat or booster seat that is appropriate for his or her size and weight.
  • Alcohol and drug use. Don’t drive under the influence of alcohol or drugs, including prescription medications that can impair the ability to drive.
  • Helmets. Wear a helmet while riding a bicycle, skateboard, motorcycle, snowmobile, or all-terrain vehicle. Also, wear appropriate head protection when playing baseball or contact sports, skiing, skating, snowboarding, or riding a horse.
  • Pay attention to your surroundings. Don’t drive, walk or cross the street while using your phone, tablet, or any smart device. These distractions can lead to accidents or falls.

Diagnosis of TBI

MRI – provides a more specific picture of the brain tissue changes.

Arterial blood gas- to determine the oxygen-carrying capacity.

Electroencephalogram (EEG) –to detect seizure activity.

CT scan – to identify the scope of injury, such as identifying subdural or epidural hematoma and to rule out fractures.

CBC – to identify hemodynamic stability and infection.

Nursing Care Plans for Traumatic Brain Injuries (TBI) Based on Diagnosis

Nursing Care Plan 1: Diagnosis – Decreased Intracranial Adaptive Capacity r/t increased intracranial pressure

Desired Outcome

  • The patient will have optimal cerebral tissue perfusion as evidenced by stable ICP and LOC.

Interventions

Monitor the patient’s neurological status, meaning the LOC, pupils, and Glasgow coma scale scores continuously.

Rationale: Subtle changes such as irritability, increased confusion, and restlessness can indicate a deterioration in status. A change in LOC may be a sign of an increased ICP (intracranial pressure).

Monitor vital signs continuously or at least every hour.

Rationale: Changes in vital signs may be a sign of increased pressure in the brain. An increased ICP causes bradycardia, a widening pulse pressure, and irregular respirations (Cushing’s triad).

Assess for fluid leakage from the ears and nose.

Rationale: Leakage from the nose (rhinorrhea) and ears (otorrhea) might be cerebrospinal fluid (CSF) after head trauma caused by fractures. Because there is no accumulation of fluid in the brain, there might be no signs of ICP.

Keep Po2 between 80 and 100 mmHg and Pco2 between 35 and 38 mmHg.

Rationale: The goal is to prevent prolonged states of hypoxemia (decreased blood level of oxygen) and hypercarbia (increased amount of carbon dioxide in arterial blood). Hypercarbia can cause cerebral vasodilation, which could cause increased intracranial pressure.

Avoid any activities and symptoms that increase ICP:

  • Position changes (keep head straight)
  • Endotracheal suctioning
  • Coughing, vomiting
  • Bending at the waist
  • Valsalva maneuvers
  • Pain
  • Fever
  • Shivering
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Rationale: These factors can increase cerebrospinal fluid and intracranial pressure. Elevation of the head of the bed and maintaining a neutral alignment help reduce venous pressure and thus decrease ICP. Limiting suctioning and hyperoxygenation before suctioning helps keep ICP at bay. Treating pain, fever, and shivering helps lower ICP as well.

Use an intracranial monitoring system.

Rationale: This equipment allows for real-time, continuous monitoring. An ICP that is greater than 15 mmHg should be reported right away.

Administer medication as ordered to decrease ICP:

  • Hyperosmotic agents (Mannitol)
  • Steroids
  • Barbiturates
  • Antipyretics
  • Muscle relaxants
  • Anticonvulsants

Rationale: Medications such as Mannitol are used to draw fluid from interstitial spaces into the intravascular space reducing cerebral edema. Steroids help reduce brain swelling. Barbiturates are used to reduce brain metabolism and blood pressure. Antipyretics lower body temperature, which lowers metabolism and cerebral blood flow, decreasing ICP. Muscle relaxants prevent shivering. Seizures might increase metabolic demands and cerebral blood flow, increasing ICP. Anticonvulsants are administered to avoid seizure activity.

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Nursing Care Plan 2: Diagnosis – Risk for Seizures

Desired Outcome

  • The patient will remain free from seizure activity and injury thereof.

Risk factors:

  • Intracranial Bleeding
  • Contusion
  • Hyponatremia
  • Open and closed brain injuries
  • Hypoxia

Protect the patient’s airway during seizure activity.

Rationale: The patient might not be able to control muscle movement during a seizure. The tongue might pose an airway obstruction by falling back into the upper airway.

Note characteristics during the seizure:

  • Onset
  • Duration
  • Type of seizure
  • Behavior at the onset, during, and after the seizure.

Rationale: Documenting these characteristics can help to identify the type of seizure and allows for more specific treatment options:

  • Maintain seizure precautions.
  • Reduce environmental stimuli
  • Pad side rails
  • Place the bed in the lowest position
  • Have suction set up and ready if needed
  • Provide head protection

Rationale: These implementations reduce the risk of injury during a seizure.

  • Assist the patient during the seizure:
  • Turn the patient’s head to the side
  • Suction if necessary
  • Administer oxygen

Rationale: These measures protect the patient’s airway during and after the seizure.

Administer anticonvulsants as ordered and check therapeutic levels regularly.

Rationale: Phenytoin (Dilantin) can only be mixed with NS. Its therapeutic level is 10 to 20 mcg/mL. Close monitoring for medication toxicity is essential. Signs include but are not limited to nausea, vomiting, restlessness, drowsiness, and visual changes.

Nursing Care Plan 3: Diagnosis – Acute Confusion r/t increased intracranial pressure

Desired Outcome

  • The patient will demonstrate a stable cognitive status as evidenced by intact LOC.

Assess the patient’s level of consciousness frequently as ordered.

Rationale: A change in mental status might indicate increased cerebral pressures.

Reorient the patient to person, time, place, and situation frequently.

Rationale: Memory might be affected that requires frequent repetition of the same information. Informing the patient about their situation might reduce anxiety levels and bring their cognitive status back to baseline.

Treat the underlying cause of the confusion.

Rationale: For increased intracranial pressure, implement measures to reduce this pressure. (See care plan above)

Introduce yourself before any interaction and procedures. Explain care in short and simple sentences before and throughout the process.

Rationale: These measures are part of reorientation. Too much information at once might increase confusion and make the patient more irritable.

Promote continuity of care.

Rationale: Frequent changes in staff and environment might further worsen the patient’s confused state. Keep the staff and environment consistent as much as possible.

If possible, have the family communicate with the patient via facetime.

Rationale: Seeing familiar faces and recognizing familiar voices might stimulate memory and help with reorientation.

Nursing Care Plan 4: Diagnosis – Deficient Knowledge r/t lack of experience with a head injury

Desired Outcome

  • The patient will demonstrate knowledge about the disease process, treatment, and prognosis as evidenced by verbalizing correct information and posing appropriate and relevant questions.

Assess the patient’s cognitive ability and receptiveness to learning information.

Rationale: Brain injury might affect short-term memory and cause behavior and mood changes. Ability to focus and learn new information might be difficult and take more time.

Assess the patient’s knowledge about the injury and treatment plan.

Rationale: Most patients and families have no prior experience with head trauma injuries. In most cases, these types of injuries arise from very sudden and unexpected events.

Update patients and family members regularly about changes in health status.

Rationale: Family members and caregivers are a vital part of the healthcare team. They can provide unique information about the patient’s baseline before the head injury.

Prepare the patient and family for the possible need for physical, occupational,  speech therapy, and ongoing home support.

Rationale: Rehabilitation can be a long process that goes beyond the hospital stay. Patients and families need to be aware of all healthcare team members. The roles of significant others might turn into primary caregiver roles after the patient is discharged. Families need help to adjust to their new roles and situation.

References

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