- Acute Confusion related to Significant blow to the head and Possible bleeding in the brain as evidenced by fluctuation in psychomotor activity and fluctuation in the level of consciousness
- Acute Confusion related to Significant blow to the head and Possible bleeding in the brain as evidenced by fluctuation in psychomotor activity and fluctuation in the level of consciousness
- Impaired Physical Mobility related to Neurological impairment as evidenced by
Reports of pain or discomfort in movement and Impaired coordination
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Hallucinations Paranoia Objective data: -Fluctuation in cognition/consciousness -Agitation/restlessness -Inappropriate perceptions -Lack of understanding or follow-through with tasks -Tremors | Acute Confusion related to Significant blow to the head and Possible bleeding in the brain as evidenced by fluctuation in psychomotor activity and fluctuation in the level of consciousness | Patient will regain alertness with orientation within normal limits. Patient will demonstrate a neurological assessment within normal limits. Patient will demonstrate appropriate motor skills and reflexes. | 1. Reorient the patient to person, time, situation, and place frequently. In concussions, memory might be affected, requiring frequent repetition of important information. Informing the patient about their situation may reduce anxiety levels and improve their awareness. 2. Allow for rest and reduce stimuli. The most important intervention after a concussion is rest. Complete darkness and quiet aren’t necessary, but brain rest is encouraged. 3. Promote safety. When in a confused state, safety is vital. Ensure frequent supervision, keep items within reach, and the bed alarm on. 4. Encourage family support. Seeing familiar faces and recognizing familiar voices stimulate memory and help with reorientation. If the patient is cleared for discharge, a family member may need to stay with them to monitor for symptoms and ensure they are recovering. | Patient regained alertness with orientation within normal limits. Patient demonstrated a neurological assessment within normal limits. Patient demonstrated appropriate motor skills and reflexes. |
| Subjective data: -Expression of pain and discomfort with movement -Refusal to move Objective data: | Impaired Memory related to Brain trauma or injury and Neurological impairment as evidenced by Difficulty recalling events and information and difficulty recalling events leading up to injury | Patient will demonstrate techniques that can help with memory loss. Patient will be able to report improved memory. | 1. Reorient the patient to their environment. Reorientation helps decrease the anxiety levels of patients with concussion and memory problems. Utilize calm conversation, taking special care not to provide details that may upset them unnecessarily. 2. Encourage the patient to use external cueing strategies. External cues can help remind patients to perform certain activities or attend to appointments or other obligations at specific times. Some of these strategies include smart alarm watches, phone alarms, calendars, written lists, and pill organizers. These assist the patient in remaining in control of their environment and schedule and help them re-establish autonomy. 3. Encourage brain rest and provide a quiet environment. Physical and cognitive rest should be encouraged for the first 24-48 hours after a concussion. Provide a dimly lit, quiet room and limit the use of screens. Once patients are symptom-free at rest, resting for more than two days has been shown to delay recovery time. 4. Refer the patient to a neuropsychologist for follow-up. Evaluation by a neuropsychologist can supplement the initial evaluation by emergency providers. Neuropsychological testing will provide information on multiple aspects of the brain that may be affected by the concussion and what issues those may cause for the patient. | Patient demonstrated techniques that can help with memory loss. Patient reported improved memory. |
| Subjective data: -Expression of pain and discomfort with movement Refusal to move Objective data: -Limited range of motion -Uncoordinated movements -Inability to turn in bed, transfer, or ambulate Gait disturbances -Contractures -Inability to follow or complete instructions | Impaired Physical Mobility related to Neurological impairment as evidenced by Reports of pain or discomfort in movement and Impaired coordination | Patient will safely participate in desired physical activities. Patient will display improvement in balance, coordination, and reflexes. Patient will perform ADLs with the least amount of assistance. | 1. Provide equipment as needed. Concussion symptoms usually aren’t severe or permanent, but the patient may need a walker or equipment temporarily to support balance and weakness. 2. Allow the patient to perform tasks at their own pace. Excessive assistance may slow their physical recovery. Take your time with the patient and encourage independent activity as allowed. 3. Encourage progressive activity as tolerated. A gradual increase in the patient’s movement will help increase their tolerance to activity. As symptoms improve, the patient should resume light exercise. 4. Refer to therapy as required. Specialized therapies such as physiotherapy and occupational therapy will provide treatment to safely improve their balance and coordination. | Patient safely participated in desired physical activities. Patient displayed improvement in balance, coordination, and reflexes. Patient performed ADLs with the least amount of assistance. |