Question

nursing care plan and nursing diagnosis on tbi

Answer 1

ANSWER.

Nursing care plan for TBI.

ASSESSMENT	NURSING DIAGNOSIS	PLANNING	IMPLEMENTATION AND RATIONALE	EVALUATION
Assessment include * Level of conciousness and orientation. * Motor movements. * Memory. * Perception. * Speech. * Vital signs. * Risk of bleeding.	Impaired physical mobility related to brain trauma. Disturbed thought process related to damage in the brain tissues. Risk of impaired skin integrity related to immobility.	Goals *Restore mobility and prevent deformities. * Improve though process of the patient. * Maintain normal skin integrity of the patient.	* Restore mobility and prevent deformities. * Assess the physical mobility level of the patient and help to maintain good body alignment to prevent contractures. * Splint application over affected extremities to prevent flexion. *Elevation of affected extremities to prevent edema. * Assist in doing a full range of motion exercises to restore motor control,joint mobility and prevent thrombosis. *Improve thought process of the patient. * Assess the mental status of the patient and begin cognitive therapy to improve cognitive function. * Effective communication with the patient to reduce stress level of the patient and improve the perfomance level of the patient. * Active listening when talking with the patient and provide emotional support to improve the psychological status of the patient. * Maintain normal skin integrity. * Assess the skin integrity of the patient which include assessment of bony areas and signs of injury,colour changes etc to detect abnormalities. * Change the position of the patient two hourly to reduce risk of pressure ulcers on the skin. * Body massages during position change will help to improve circulation and reduce skin breakdown. * Providing adequate nutritious foods to maintain normal skin function.	Evaluate the activity level of the patient. Evaluate the cognitive function of the patient. Evaluate the skin integrity of the patient.