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nursing care plan and nursing diagnosis on tbi

Expert Solution

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.

Nightingale answered 2 years ago

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nursing care plan and nursing diagnosis on tbi

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