Nursing Process
The Patient with a Traumatic Brain Injury
Assessment
Depending on the patient's neurologic status, the nurse may elicit information from the
patient, from the family, or from witnesses or emergency rescue personnel. Although
all usual baseline data may not be collected initially, the immediate health history
should include the following questions:
When did the injury occur?
What caused the injury? A high-velocity missile? An object striking the head?
A fall?
What was the direction and force of the blow?A history of unconsciousness or amnesia after a head injury indicates a significant
degree of brain damage, and changes that occur minutes to hours after the initial injury
can reflect recovery or indicate the development of secondary brain damage. Therefore,
the nurse also should try to determine if there was a loss of consciousness, what the
duration of the unconscious period was, and whether the patient could be aroused.
In addition to asking questions that establish the nature of the injury and the patient's
condition immediately after the injury, the nurse examines the patient thoroughly. This
assessment includes determining the patient's LOC using the Glasgow Coma Scale and
assessing the patient's response to tactile stimuli (if unconscious), pupillary response to
light, corneal and gag reflexes, and motor function. The Glasgow Coma Scale (Chart
63 - 4) is based on the three criteria of eye opening, verbal responses, and motor
responses to verbal commands or painful stimuli. It is particularly useful for monitoring
changes during the acute phase, the first few days after a head injury. It does not take
the place of an in-depth neurologic assessment. Additional detailed assessments are
made initially and at frequent intervals throughout the acute phase of care (Hickey,
2003). The baseline and ongoing assessments are critical nursing interventions for the
patient with brain injury, whose condition can worsen dramatically and irrevocably if
subtle signs are overlooked. More information on assessment is provided in the
following sections and in Figure 63-5 and Table 63-1.
Diagnosis
Nursing Diagnoses
Based on the assessment data, the patient's major nursing diagnoses may include the
following:
Ineffective airway clearance and impaired gas exchange related to brain injury
Ineffective cerebral tissue perfusion related to increased ICP, decreased CPP,
and possible seizures
Deficient fluid volume related to decreased LOC and hormonal dysfunction
Imbalanced nutrition, less than body requirements, related to increased
metabolic demands, fluid restriction, and inadequate intake
Risk for injury (self-directed and directed at others) related to seizures,
disorientation, restlessness, or brain damage
Risk for imbalanced body temperature related to damaged temperature-
regulating mechanisms in the brain