Nursing Diagnosis for Brain Injury

A brain injury is any injury occurring in the brain of a living organism. Brain injuries can be classified along several dimensions. Primary and secondary brain injury are ways to classify the injury processes that occur in brain injury, while focal and diffuse brain injury are ways to classify the extent or location of injury in the brain. Specific forms of brain injury include:
  • Brain damage, the destruction or degeneration of brain cells.
  • Traumatic brain injury, damage that occurs when an outside force traumatically injures the brain.
  • Stroke, a vascular event causing damage in the brain.
  • Acquired brain injury, damage to the brain that occurs after birth, regardless of whether it is traumatic or nontraumatic, or whether due to an outside or internal cause.
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Nursing Diagnosis for Brain Injury
  1. Ineffective airway clearance and impaired gas exchange related to brain injury
  2. Ineffective cerebral tissue perfusion related to increased ICP, decreased CPP, and possible seizures
  3. Deficient fluid volume related to decreased LOC and hormonal dysfunction
  4. Imbalanced nutrition, less than body requirements related to increased metabolic demands, fluid restriction, and inadequate intake
  5. Risk for injury (self-directed and directed at others) related to seizures, disorientation, restlessness, or brain damage
  6. Risk for imbalanced body temperature related to damaged temperature-regulating mechanisms in the brain
  7. Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, immobility, or restlessness
  8. Disturbed thought processes (deficits in intellectual function, communication, memory, information processing) related to brain injury
  9. Disturbed sleep pattern related to brain injury and frequent neurologic checks
  10. Interrupted family processes related to unresponsiveness of patient, unpredictability of outcome, prolonged recovery period, and the patient’s residual physical disability and emotional deficit
  11. Deficient knowledge about brain injury, recovery, and the rehabilitation process

Source : amy47.wordpress.com

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