Nursing Care Plan: Traumatic Brain Injury.

 Preparing for Professional Practice
Knowing the Nursing Profession

In cases of traumatic brain injuries nurses play an important role in providing supportive care but alsoeducation (Moyle, 2016). Since the disease is chronic and often affects older patients, comorbidities play asignificant role in how to help clients manage their condition. Continual monitoring of the patient is required as cognitive deficits, cardiovascular system problems, and genitourinary problems are common (Moyle, 2016).

Knowing the Self

My background in health sciences will be an asset in helping me to understand how the social determinants of health contributed to the patients’ disease state and how they may impact his recovery process.  Along with anatomy and physiology I will be able to understand some of the disease mechanismsof how the lungs and oxygen transport work. Lastly, pharmacology will have prepared me in understanding how drugs may improve or regulate conditions related to traumatic brain injuries and the drug mechanisms, the class of drugs, and where to look up drug information to understand the role of the drug.

While I feel confident in my ability to perform a head to toe assessment, at times I feel uncomfortable to use my knowledge to facilitate my understanding of what I may be looking for particularly when faced with a new case. However, I believe one of my greatest strengths is the ability to ask for help or to clarify my understanding of things when I am unsure of what to do.

Having done some preliminary research into traumatic brain injuries, I feel that the client will likely be lack the ability or have difficulty communicating their thoughts and pain perception, the client will likely lack the ability to follow basic commands, and have no purposeful movement.


1.      Understand what how brain damage can impact a patient’s quality of life

2.      Become comfortable performing a head to toe assessment and being able to differentiate between normal sounds

3.      Understand how brain injuries can cause problems with automatic nervous system regulation (ex. Tachycardia, bradycardia, temperature regulation) 

Knowing the Case or Patient Population

Diagnosis and Pathophysiology

Traumatic brain injury severity is commonly described as mild, moderate, or severe. Injury severity is traditionally based on duration of loss of consciousness and/or coma rating scale or score, and brain imaging (Northeastern University, 2010).

Severe TBI may be further subcategorized as follows:

1.      Coma- a state of unconsciousness from which the individual cannot be awakened

2.      Vegetative State- a state in which an individual is not in a coma (i.e. awake) but is not aware of theenvironment

3.      Persistent Vegetative State- a vegetative state that has lasted for more than a month

4.      Minimally Responsive State- a state in which a person with a severe TBI is no longer in a coma orvegetative state and inconsistently interacts with/responds to the environment.

Symptoms and Diagnosis:

Brain injuries can vary from mild to severe. However, severe symptoms can vary depending on the severity of the injury, difficulty with perception and sensory system, unable to control eating, and the loss of bowel and bladder functions. Severe brain injuries have been defined as a brain injury where the patient has lost consciousness for over 6 hours and scores a 3 on the Glasgow Coma Scale.

Common Risk Factors

Motor vehicle accidents, contact sports, blunt trauma (intentional or unintentional), or falls (Northeastern University, 2010).


Treatment is dependent on the severity of injury but can range from compensatory to restorative strategies.  

Expected Findings: 

Some patients acutely recovering from head trauma demonstrate no ability to retain new information.

Other findings may be a loss of consciousness, loss of coordination, edema (particularly in the head cavity), unequal pupils, nausea and vomiting, changes in mood, bradycardia, increased blood pressure, and altered respirations (Edgerly, 2008).

Nursing Role:

Patients with severe traumatic brain injuries have a poor prognosis and therefore it is important nursinginterventions promote compassionate quality care to enhance patient comfort as the change in conditioncan be distressing depending on the severity for the client and their loved ones. It is important that thenurse monitor vital signs closely, watching pulse rate, blood pressure and pulse pressure for trends thatmay result in the Cushing’s response (ie. Altered respirations, increased BP, and bradycardia) (Edgerly, 2008) .

Management of severe TBI patients requires multidisciplinary approach (ex. Coordinating with OT, PT, RT, physician, social worker), frequent close monitoring, and use of multiple treatments to lessen secondary brain injury in an effort to try to improve outcomes.

During the Professional Practice Experience
Knowing the Individual . . .
As a Patient

What makes my patient differentfrom or the same as thetypicalcases? Whats thenormal” (i.e., baseline) for my patient?


Unfortunately, I was not able toconverse much with my patient or their family and was therefore unableto gain an understanding of hisbaseline prior to his injury. In comparison to the two weeks that I worked with this patient it was evident that his condition was deteriorating (ie. Weight and heart rate both decreased).


Compared to other patients, he was in a persistent vegetative state. With traumatic brain injuries, there tends to be variation in how it clinically manifests in some patients compared to others. This week my patient was not at baseline as he had a severe allergic reaction to Vancomyosin, and developed a severe rash and blisters. He also became tachycardic which was higher than his normal baseline which was normally WNL. 

As a Person 

Patient is an older gentleman who emigrated to Canada from Beijing. Patient was riding his bike along a common route when he was stuck by a car and acquired a brain injury requiring transport to a specialized Centre in Hamilton. In this case, he immigrated to Canada later in his life and was not able to communicate in English. According to his family, he wished to remained on life sustaining measures.

Unfortunately, due to the nature of the sustained injury, the patient is presumed to be in a persistent vegetative state and it is therefore highly unlikely he will ever return to a state where he would be able to function independently or return to consciousness. The goal in this case would be to find a specialized care center where he could enter palliative treatment.

NoticingGathering Cues & Information

You need to gather data/ cues/ information from a wide variety of areas in order to thoroughly determinethe main issues that are affecting your patient. Look for the following information:

Chart Data

Admission note, medical history, report, progress notes (various members of healthcare team)

–       Patient immigrated from China into the local area and unable to speak English.

–       Was riding his bike when he was hit by a car and as a result suffered from a severe head injury

–       Received a subarachnoid hemorrhage that was unable to be cleared and as a result lost brain function and is not presumed to be in a vegetative state.

–       Has had multiple rebleeds and surgeries (left temporal craniotomy) and transported between Hamilton Health Sciences and Kitchener for medical treatment.

–       Patient is in his mid-70’s with a wife and one son who is fluent in English.

–       Patients condition has continually deteriorated over time and multiple meeting had been set up with medical team, social workers, and family to discuss future plans.

–       He was otherwise healthy prior to the car accident

Treatment Plan

Medication record, code status, treatments (IV, positioning, oxygen, diet, activity, dressings)

·       Pureed diet

·       Patient breathes through a trach tube and is on room air

·       Patient unable to perform activities of daily livingon his own with assistance from nurses, OTs, or other healthcare providers

·       Patient moved from bed to chair for portion of day

·       Patient is weighed every Thursday

·       Dressing on coccyx changed every Monday and Thursday

·       Patient’s left arm is restrained to prevent tubes from being ripped out

·       Metoprolol, Colecalcferiol, Levothyroxine, Silodosin, Lansoprazole, Vancomyosin







Lab & Diagnostic Reports

What do these findings mean for this patient?


–       Occult blood- Positive

–       RDW- 17.3- Has been noted to be a sign of heart failure in elderly patients (he was noted to have atrial fibrillation- which is the most common form of heart failure) (Nishizaki et al., 2012).


Cues from my Patient

·       Patient was unresponsive and unable to communicate with those looking after his assessments and personal hygiene.

·       Patient expected to move into palliative care upon consultation between social workers, physicians, nurse practitioner, and family.

·       Patient is “responsive” when suctioning out trachea or when touching patient (ie. Opens eyes), however as his care provider it is hard to tell if he is comfortable or whether it is just coincidence.

·       It is obvious his body has begun to shut down as he is unable to keep on any weight and his vital signs have begun to deteriorate within two weeks of last working with him.  


My Assessments (initial assessment and focused cardiac, respiratory, GI, neurological, pain, skin, musculoskeletal)

Physical assessment:

Edema in his left arm with noted rash (vibrant red), and blisters

Unable to ambulate self out of bed

Pressure ulcer on coccyx

Weight has consistently dropped over time.

Dry skin, skin is cold

Pic line in right arm



BP- 125/67 but went up to 136/167

Pulse- 98, in chair-60

RR- 10

Temp- 36.4 

Respiratory assessment:

Lungs sounds were relatively normal

Fluid build up cleared multiple times a shift

Trachea tube- around 99% room air

Pleural Effusion in the past

GI Assessment:

Bowel sounds were normal

Continuous feed (G tube)

One bowel movement noted during bed bath

Neurological Assessment:

Limited capacity

Presumed to be in a persistent vegetative state as he is non-responsive to pain and unable to follow commands

Reflexes were uncontrolled and restraint was placed on left arm to prevent patient from pulling out trachea tube.

Muscles were rigid and patient prefers to stay in a state of flexion.

Cardiovascular Assessment:

Tachycardia as of the morning- likely due to allergic reaction he experienced

Atrial fibrillation  



InterpretingRecognizing Patterns & Interpreting Data RespondingDetermining a Course of Action

*Choose any identified issue and complete the care plan below.*

Key Issues Rationale
What are the most important issues for your patient? What subjective and objective cues/assessments indicate that these issues exist? What needs to be attended to first and why? Provide support for your ranking. Goals/Outcomes

What are the desired short and long term goals?

(Use SMART goals)


What course of action of interventions would address the identified issue? How will continued noticing/interpreting influence these actions.


What are the reasons for my decisions and actions? How does literature/evidence support these actions?

1.      Cognitivedeficits




2.      Skinintegrityissues




3.Cardiovascularissues (HR was hovering around 47 bpm)






1.      Mental healthassessment orthe use of theGlasgow ComaScale




2.      Assessment ofthe skin, particularlywhen lookingat his arm from a likely severe allergic reaction


3.      Cardiovascularassessment orthe use ofcariacmonitors tomonitor rate





1.      Heart rate should be monitored constantly and attended to first as autonomic nervous system is often compromised and can vary. Monitoring changes can hopefully help to lessen deteriorating health and cardiac arrest.

2.      Determining patient’s cognitive 🤑status and taking preventative measures (ex. Armrestraints)

3.      Assessment of skin and applying comfort measures and making sure to avoid infection or deterioration of skin. This would include cleaning the area and ensuring arm safely positioned in way patient could not pop blisters.





S- Patient developed a severe rash andheart rate had anoticeableincreased overthe past few hours and was on an antibiotic to treat Osteomyelitis of scalp, which was being administered by IV. I would want to make sure that the medication being administered remains safe. In meantime, I would stop medication until given the green light to restart.


M- Making sure heart rate stays within safe limits as set out by their MAR, I would ask for the physician and pharmacist to verify whether the medication was the cause of the severe reaction

A- Evaluate continuous vital sign surveillance as a tool to improve patient safety. Would also assess arm every hour to ensure rash and blisters have not spread further on his body to other areas.


R- Upon stopping medication, patient remains free of side effects and the patient’s HR stays within safe limits to avoid cardiac arrest.Monitoring vital signs every hour or so is achievable as resources are easily available to use.


T- Every shift that I would be present I would make an effort to check in on the patient, particularly after any future antibiotics have been administered.

As previously mentioned, monitoring of the patients vital signs and monitors will help indicate whether the patient’s heart rate has changed. Changes in respiratory rate or pulse can indicate changes in cardiac output or heart failure. As the patient is unable to communicate, it would be important to be consistent with monitoring the patient to be able to differentiate from what is normal for the patient.

It would also be important to chart any side effects the patient may experience after administering their medication. As this patient had been on the antibiotic for a few weeks, it was odd that he developed a sudden allergic reaction. I would be concerned that other medications could interact with future anti-biotic use and that his wounds may take longer to heal to due his deteriorating condition.




·       Patient safety wouldbe my utmostpriority.


Stopping the medication being administered to the area directly would be the most logical decision as evidenced in our Medication Safety lecture in pharmacology class.


It would also be important to discuss the findings with the MRP and pharmacist to ensure the patient does not experience any further complications and is still able to receive the necessary treatment for infection (if needed).


Edgerly, D. (2008, October 31) Brain injury basics. Retrieved December 22, 2017, from

Moyle, S. (2016, August 23). Traumatic brain injuries. Retrieved December 22, 2017, from

Nishizaki Y, Yamagami S, Suzuki H, Joki Y, Takahashi S, Sesoko M, Yamashita H, Kuremoto K, Shinozaki T, Daida H. (2012). Red blood cell    distribution width as an effective tool for detecting fatal heart failure in super-elderly patients. Internal Medicine, 51(17). Retrieved December 23, 2017, from

Northeastern University (2010). Traumatic brain injury resource for survivors and caregivers. Retrieved December 22, 2017, from



After the Professional Practice Experience
ReflectionOn Action and Clinical Learning
How did the course of action meet my patients needs? Were outcomes achieved? What were my strengthstoday? What areas could I work on? What did I learn from my patient today? What did I learn aboutmyself?

The crucial step of stopping the medication was effective in preventing the patient from experiencing more adverse side effects and stop the spread of the rash. The outcomes were achieved.

Today I learned how to suction out a trachea tube, which was something not discussed in clinical labs. While it was exciting to learn something new, it also brought up the issues of how life-sustaining measures may not always bring benefit to the patient in terms of improving their overall quality of life. Watching this particular patient was hard as it was evident he had not awareness of his surroundings and it was also a little disheartening to see how uncomfortable it would be to be bed ridden all day and be restrained in moving his arms.

I could work on building my confidence. The first hour was the most nerve wrecking hour as I felt like I did not know or prepare enough for the clinical experience. However, as time went on and I felt comfortable enough to ask questions I was able to enjoy my first clinical experience having my own patient and have a better understanding of the nurses role.

Today, I learned that like anything else in life, it takes practice to be a good nurse. I was fortunate enough to be placed with a partner who I felt was at the same level as me and a nurse who was also relatively new to the profession helping to guide us throughout the day.


Gillespie, M., Using the SituatedClinicalDecision-Making framework to guide analysis of nurses’ clinical decision-making, Nurse Education in Practice(2010), doi:10.1016/j.nepr2010.02.003) 

Tanner, C. A., Benner, P., Chesla, C., Gordon, D.R. (1993). Thephenomenologyofknowingthepatient.  Image: JournalofNursingScholarship, 25 (4), 273-280.