Pain related to injuries sustained at the time of traumatic brain injury

Outcome: the client will have pain control and will not become depresses as a result of pain

Interventions:

• Educate client regarding medications, dosage and side effects --- understanding of all medications allow for
more appropriate choices.
• Provide information about appropriate pain management and weaning from pain medications--- excessive use
of pain medication can cause tolerance and may require additional support for weaning
• Assess client’s level of pain and if client can’t verbally express pain, use other pain assessment. ---pain
management begins with pain assessment
• Educate client about analgesics and appropriate management of pain using various types of analgesia.—
understanding analgesia option helps the client in decision making for pain relief.

Eval: the client will have comfort at tolerable level and will develop self-management plan for pain relief.

Impaired skin integrity Rt prolong bed rest

Outcome: the client will have no evidence of skin breakdown or poor wound healing.

Interventions

• Assess akin every shift to identify potential pressure areas and begin treatment if necessary--- clients who are
on bed rest have increase risk of skin breakdown from pressure.
• Turn client every two hours--- turning relieves pressure
• Assess incision line to ensure that it remains clean, dry and intact--- infection may cause delay in healing
• Provide appropriate care to incision line – to promote healing

Eval: the client’s skin will remain intact and incision will heal in timely manner.
Imbalanced nutrition: less than body requirements Rt inability to consume food as a result from traumatic brain
injury.

Out: the client will remain normal weight and will consume balance diet

Inter:

• Assess caloric consumption=-- to many calories or too few calories can inhibit healing
• Provide information about appropriate dietary intake— many clients need info about proper dietary intake
which will prevent future health care problems
• Educate regarding wt loss or wt gain—this affects strength and ability to regain independence

Eval: the client maintain appropriate intake without excessive wt loss or gain

Self care deficit: bathing/hygiene, dressing/grooming, feeding, oral hygiene, toileting

Out: the client will have a satisfactory el-care as evidence by performing as many activities of daily living as
possible.

Inter:

• Assist client in doing ADl—it increases independence

• Provide education regarding feeding and swallowing—carefull monitoring of foof intake and appropriate
feedinf techniques will minimize aspiration
• Provide education about bowel regimen—a regular bowel regimen will promote bowel continence and
prevent constipation

Eval: the client will become independent as possible in all activities of daily living.

Urinary retention due to traumatic brain injury affecting neuronal control of the bladder
Out: the client will be continent and without bladder distention

• Assess for bladder distention, particularly after urinary catheter is removed—bladder distention is a coomon
problem after brain injury and can contribute to UTI
• Insert urinary catheter is client is unable to void. —catheterization removes excess urine and decreases the
likelyhood of infection from urine retention.
• Assess the volume, color, odor of urine; frequency of urination; difficulty with urination and overflow of
urination—voiding high volume of urine could be related to dieresis or to diabetes insipidus.

Eval: the client will be able to void,

Sleep deprivation RT traumatic brain injury, lack of sleep in hospital, and changes in diurnal patterns from
hospitalization

Out: the client will report a normal sleep pattern

Inter:

• Assess the client’s mood and ability to tolerate stressful situations.

• Provide opportunities to sleep inability to sleep leads to intolerance in stressful situations, delay healing
and recovery, and slows rehabilitation process.
• Assess medications and provide temper mood and promote sleep.—medications may be necessary to
assist in stabilizing sleep pattern
• Encourage increase activity during the day. – it will promote sleep
• Avoid long naps during day.—naps during day will prevent long periods of sleep at night.

Eval: after interventions, the client will return to a normal sleep schedule and will able to tolerate stress daily.