- Acute Confusion related to Brain injury and Neurologic trauma as evidenced by Cognitive dysfunction and Misperception
- Deficient Knowledge related to Cognitive dysfunction and Neurobehavioral manifestations as evidenced by Inappropriate behaviour and development of further complications
- Ineffective Breathing Pattern related to Brainstem impairment and respiratory muscle weakness as evidenced by Bradypnea and Hypoxemia
| 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 Brain injury and Neurologic trauma as evidenced by Cognitive dysfunction and Misperception | Patient will maintain a baseline level of consciousness and will not experience decreased memory. Patient will be able to respond appropriately to questions. | 1. Ensure patient safety. Patients with acute confusion are not able to follow directions. It is important to promote patient safety by providing a hazard-free environment. 2. Reorient the patient as needed. Patients with mild TBI may be disoriented and may exhibit short-term memory loss. Frequent reorientation is essential before any interaction to promote a trusting relationship and cooperation from the patient. 3. Keep explanations and activities short and simple. This allows the patient to better understand the instructions and procedures performed. It is vital to give these explanations before and throughout the patient’s care. They are unlikely to remember long instructions so keep teaching sessions short. 4. Eliminate extraneous noise as necessary. This can help reduce the patient’s anxiety, confusion, and exaggerated emotional responses associated with sensory overload. 5. Provide structured therapies and activities. This will help promote consistency and reassurance, reduces the patient’s anxiety and confusion, and promotes a sense of control. | Patient maintained baseline level of consciousness and will not experience decreased memory. Patient will be able to respond appropriately to questions. |
| Subjective data: Verbalizes poor understanding Seeks additional information Denial of a need to learn Objective data: -Inaccurate demonstration or teach-back of instructions -Inability to recall instructions -Exhibiting aggression or irritability regarding teaching follow-up -Poor adherence to recommended treatment or worsening medical condition -Avoiding eye contact or remaining silent during teaching | Deficient Knowledge related to Cognitive dysfunction and Neurobehavioral manifestations as evidenced by Inappropriate behaviour and development of further complications | Patient and/or family will demonstrate knowledge about the condition, treatments, and prognosis as evidenced by verbalization of teaching instructions and adherence with follow-up activities. | 1. Encourage the patient to participate in developing a relevant treatment regimen. This will let the patient feel a sense of control in their treatment regimen and likely result in the best outcomes. 2. Encourage the patient and family to participate in required therapies. Rehabilitation may be indicated for patients after TBI to maximize return to the patient’s highest level of functioning. The patient’s family may be required to provide continuous support to the patient even after the patient is discharged. 3. Discuss possible changes in behavior, mood, and personality at home. Personality and behavioral problems can develop after TBI. The family must be prepared to cope with the possible changes in the patient’s behavior, personality, and mood. 4. Discuss the importance of follow-up care. Follow-up care is essential in ensuring the patients return to their highest level of functioning. 5. Instruct the family to develop a structured and consistent home routine. Patients suffering from TBI respond best to a structured and consistent environment that does not deviate much from their normal routine. | Patient and family demonstrated knowledge about the condition, treatments, and prognosis as evidenced by verbalization of teaching instructions and adherence with follow-up activities. |
Subjective data: Difficulty breathing; shortness of breath or dyspnoea Anxiety in relation to breathing Objective data: -Dyspnoea -Abnormal respiratory rate; tachypnoea or bradypnea -Poor oxygen saturation -Abnormal ABG results -Shallow breathing -Pursed-lip breathing -Accessory muscle use when breathing -Nasal flaring -Cough -Restlessness and anxiety -Decreased level of consciousness | Ineffective Breathing Pattern related to Brainstem impairment and respiratory muscle weakness as evidenced by Bradypnea and Hypoxemia | Patient will maintain arterial blood gases within an acceptable range. Patient will not require the use of mechanical ventilation. | 1. Position the patient with the head of the bed elevated 30-45 degrees. Elevating the head of the bed can help reduce increased intracranial pressure in patients with TBI and, at the same time, promote lung expansion for optimal breathing. 2. Administer supplemental oxygen as indicated. TBI can cause hypoxia, so oxygen supplementation is essential to reverse tissue hypoxia, enhance breathing patterns, and promote oxygen exchange. 3. Assist in providing ventilatory support. Severe cases of TBI may require mechanical ventilation to help protect the airways, promote normal breathing patterns, and prevent hypoxemia. 4. Encourage breathing exercises and ambulation. Breathing exercises, along with early ambulation, can significantly improve cardiorespiratory fitness after TBI. | Patient maintained arterial blood gases within an acceptable range. Patient required the use of mechanical ventilation. |