Nurses Compass
Care Plan for Traumatic Brain Injury Management
Category: Neurological
Assessment
Patient presents with headache, confusion, and decreased level of consciousness following a head injury.
Diagnosis
Risk for ineffective cerebral tissue perfusion related to traumatic brain injury.
Goals
Patient will demonstrate stable neurological status as evidenced by GCS of 15 and absence of focal deficits. Patient's intracranial pressure will be maintained within normal limits.
Interventions
Monitor neurological status and vital signs every 1-2 hours. Administer prescribed medications to reduce intracranial pressure (e.g., mannitol). Elevate the head of the bed to 30 degrees to promote venous drainage. Prepare patient for possible surgical intervention if indicated (e.g., craniotomy).
Rationale
These interventions aim to reduce intracranial pressure, prevent further neurological deterioration, and promote cerebral perfusion.
Evaluation
Neurological status and intracranial pressure will be monitored to evaluate the effectiveness of interventions.