TRAUMATIC BRAIN INJURY PREOPERATIVE NURSING CARE PLAN
ASSESSMENT
NURSING
DIAGNOSIS
Subjective data: Acute pain
Pati
related to
destructio
On arrival at
n of nerve
the emergency tissue and
department
infiltration
(ED), he was
of nerves
combative and and
vomiting
vascular
Objective cues: supply as
1. Guarding
evidenced
behavior,
by
protecting
alteration
his left leg
of muscle
and knee
tone and
areas
facial tone
2. Facial mask
of pain was
noted
3. Has gnawing
pain in his
left knee
with a pain
scale of
8/10
GOALS
INTERVENTIONS
Short term goal:
At the end of 4
hours of nursing
interventions the
patient will be
able to:
 Understand
the use
pharmacolog
ical and nonpharmacolog
ical painrelief
strategies
such deep
breathing
exercises
and
diversional
activities
Independent:
1. Assessment of pain
1. Assessed pain
experience is the
characteristics:
first step in planning
 Quality (e.g.,
pain management
strategies. The most
burning, sharp,
reliable source of
shooting)
information about
 Severity (scale of 0
the pain is the
or no pain to 10 or
patient. Descriptive
most severe pain)
scales such as a
 Location
visual analogue can
(anatomical
be utilized to
description)
distinguish the
 Onset (gradual or
degree of pain.
sudden)
 Duration (how
long; intermittent or 2. Some people deny
the existence of
continuous)
pain. Attention to
 Precipitating or
associated signs
relieving factors
may help the nurse
in evaluating pain.
2. Assessed for signs
An increase in BP,
and symptoms
HR, and
relating to pain.
temperature may be
present in a patient
with acute pain. The
patient’s skin may
be pale and cool to
touch. Restlessness
and inability to
Long term goal:
RATIONALE
EVALUATION
Short term goal:
GOAL’S MET
Understand the use
pharmacological and
non-pharmacological
pain-relief strategies
Long term goal:
GOAL’S PARTIALLY
MET
Patient verbalized
alleviation of pain from
pain scale of 8/10 to
5/10
And Patient still with
no display of
improvement in mood
and coping.
Lewis J. R. (2016). Traumatic brain injury and the evidence for its management. BMJ case reports, 2016, bcr2015213039.
https://doi.org/10.1136/bcr-2015-213039
PREOPERATIVE NURSING CARE PLAN
At the end of 8
hours of nursing
intervention the
patient will be
able to:
 Verbalize
alleviation of
pain from
8/10 to 4/10
 Patient
displays
improvement
in mood,
coping.
concentrate are also
some
manifestations.
3. Assessed the
patent’s
anticipation for
pain relief.
4. Evaluated the
patient’s response
to pain and
management
strategies.
3. Other patients may
be overlooking of
the effectiveness of
nonpharmacological
methods and may
be willing to try
them, either with or
instead of traditional
analgesic
medications. Often
a combination of
therapies (e.g., mild
analgesics with
distraction or heat)
may be more
effective. Some
patients will feel
uncomfortable
exploring alternative
methods of pain
relief. However,
patients need to be
acquainted that
there are other
approaches to
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PREOPERATIVE NURSING CARE PLAN
manage pain.
4. The meaning of pain
5. Acknowledged
will directly
reports of pain
determine the
immediately. And
patient’s response.
Get rid of
Some patients,
additional stressors
especially the dying,
or sources of
may consider that
discomfort
the “act of suffering”
whenever possible
meets a spiritual
need.
6. Provided rest
periods to promote
relief, sleep, and
relaxation.
Dependent:
7. Determined the
appropriate pain
relief method.
Pharmacological
methods include the
following:
5. One’s experiences
of pain may become
exaggerated as a
result of exhaustion.
Pain may result in
fatigue, which may
result in
exaggerated pain. A
peaceful and quiet
environment may
facilitate rest.
6. Patients may
experience an
exaggeration in pain
or a decreased
ability to tolerate
painful stimuli if
environmental,
intrapersonal, or
intrapsychic factors
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PREOPERATIVE NURSING CARE PLAN
are further stressing
them.
 Nonopioids
(acetaminophen), a
7. Patients with acute
nonselective
pain should be
NSAID, or a
given a nonopioid
selective NSAID
analgesic around(e.g.,
the-clock unless
cyclooxygenase
contraindicated.
[COX]-2 inhibitor)
8. Encouraged
patient with the
significant others
such as Cognitivebehavioral
strategies as
follows:
 Imagery
 Distraction
techniques
 Relaxation
exercises,
biofeedback,
breathing
exercises, music
therapy
 NSAIDs work in
peripheral tissues.
Some block the
synthesis of
prostaglandins,
which stimulate
nociceptors. They
are effective in
managing mild to
moderate pain.
8. The aid of an
imagined event or a
mental picture
involves use of the
five senses to divert
oneself from painful
stimuli. Increasing
one’s concentration,
these techniques
help an individual
decrease the pain
experience.
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PREOPERATIVE NURSING CARE PLAN
Breathing
modifications and
nerve stimulations
are some of the
methods. The aim of
these techniques is
to lessen the stress,
tension,
subsequently
decreasing the pain.
FIRST PRIORITY: ACUTE PAIN RELATED TO DESTRUCTION OF NERVE TISSUE AND INFILTRATION OF NERVES AND
VASCULAR SUPPLY AS EVIDENCED BY ALTERATION OF MUSCLE TONE AND FACIAL TONE
SECOND PRIORITY: IMPAIRED AIRWAY CLEARANCE RELATED TO STASIS OF SECRETIONS SECONDARY TO
PRODUCTIVE COUGH
ASSESSMENT
Subjective:
“Maglisud ko ug
ginahawa usahay
maam”, as verbalized
by the patient
Objectives:
 Respiratory
NURSING
DIAGNOSIS
OBJECTIVES
Impaired
airway
clearance
related to
stasis of
secretions
secondary to
productive
Short Term:
At the end of 4
hours nursing
intervention, the
patient or the
significant others
will be able to
verbalize
INTERVENTIONS
Independent
1. Place patient with
proper body
alignment for
maximum breathing
pattern.
2. Monitored vital signs
RATIONALE
3. A sitting position permits
maximum lung excursion
and chest expansion.
2. To monitor patient’s
EVALUATION
Short Term:
GOALS PARTIALLY MET
as evidence by:
a. Verbalization of
importance of proper
positioning during
breathing and
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PREOPERATIVE NURSING CARE PLAN






rate = 30cpm
Use of
accessory
muscles when
breathing
Fast and
laboured
breathing
Productive
Cough with
yellowish
secretion
Crackles noted
upon
auscultation
O2 saturation
– 94%
c O2 inhalation
at 2-4 LpM
cough
understanding on
health teachings
imparted with
emphasis on deep
breathing
exercises and
positioning for
proper lung
expansion
Long term:
At the end of 16
hours nursing
intervention, the
patient will be able
to:
1. Maintain an
effective
breathing
pattern, as
evidenced by
relaxed
breathing at
normal rate
and depth
and absence
of dyspnea.
2. Patient
indicates,
either verbally
or through
behavior,
(BP, O2 sat, Temp,
RR and PR)
3. Encourage sustained
deep breaths by:
Using demonstration:
highlighting slow
inhalation, holding
end inspiration for a
few seconds, and
passive exhalation
Utilizing incentive
spirometer
Requiring the patient
to yawn
4. Maintain a clear
airway by
encouraging patient
to mobilize own
secretions with
successful coughing.
Dependent:
1. Provide respiratory
medications and
oxygen, per doctor’s
orders.
status and provide
necessary intervention
3. These techniques
promotes deep
inspiration, which
increases oxygenation
and prevents atelectasis.
Controlled breathing
methods may also aid
slow respirations in
patients who are
tachypneic. Prolonged
expiration prevents air
trapping.
breathing exercises
Long Term:
GOALS PARTIALLY MET
as evidence by:
a. Verbalized alleviation of
difficulty of breathing
and has an RR of
25cpm
.
4. This facilitates adequate
clearance of secretions.
Dependent:
Beta-adrenergic agonist
medications relax airway
smooth muscles and
cause bronchodilation to
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PREOPERATIVE NURSING CARE PLAN
feeling
comfortable
when
breathing.
open air passages.
THIRD PRIORITY: IMPAIRED PHYSICAL MOBILITY RELATED TO PAIN SECONDARY TO MALIGNANT TUMOR AT L
KNEE
ASSESSMENT
Subjective:
“ Sakit kaayo ilihok
maam maong mag
sige nalang siya
higda.” As verbalized
by the patient’s
significant other.
NURSING
DIAGNOSIS
Impaired
Physical
mobility related
to pain
secondary to
malignant tumor
at L knee
OBJECTIVES
Short Term:
At the end of 4
hours nursing
intervention, the
patient or the
significant others
will be able to
verbalize
INTERVENTIONS
Independent
1. Identify factors such as
age, functional decline,
client resistive to efforts,
painful conditions and
others.
2. Monitored vital signs
RATIONALE
1. These could affect the
desired level of activity
2. To monitor patient’s
EVALUATION
Short Term:
GOALS PARTIALLY MET
as evidence by:
b. Patient’s significant
other stated 2
management on how to
increased physical
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PREOPERATIVE NURSING CARE PLAN
Objectives:
 Pain scale of
8/10
 Limited range
of motion.
 Appears weak
 (+) facial
Grimace
 Immobile
 Tumor at left
knee
understanding on
health teachings
imparted and
reduced discomfort
and pain as
evidence by:
a. Stating at least
2 management that
will help increased
physical mobility
and strength such
as (Eating
Nutritious food rich
in Calcium, Doing
Passive and Active
ROM).
b. Pain scale of
less than or equal
7
and cognitive signs
status and provide
necessary intervention
mobility and strength
c. Pain scale of 5/10
3. Provided health
teachings on how to
improve physical
mobility and strength
4. Assessed
Pain scale frequently
and provided comfort
measures.
5. Provided calm and quiet
environment
4. Adequate information is
necessary for the client to
facilitate self- confidence
and participation in
improving his own
physical mobility and
strength.
.
5. Pain affects tolerance to
perform activities.
6. To decrease
environmental factors
which contribute to pain.
6. Maintained side rails up
7. Assisted in transferring
the patient to Operating
room table
Dependent:
8. Administer pain
medications if indicated
(Ketorolac).
7. To prevent physical
injuries and maintain
client’s safety.
8. To reduce patient’s pain
and provide relief.
Reduces pain by directly
targeting affected area by
disrupting prostaglandin
synthesis
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PREOPERATIVE NURSING CARE PLAN
FOURTH PRIORITY: IMPAIRED TISSUE (SKIN) INTEGRITY RELATED TO ALTERED CIRCULATION SECONDARY TO
MALIGNANT TUMOR OF THE RIGHT KNEE AS EVIDENCED BY DAMAGED OR DESTROYED TISSUE AND BLEEDING
ASSESSMENT
Subjective cues:
“Nagsamad samad ug
ga dugo na siya dugay
na maam” as
verbalized by the
patient
Objective cues:
NURSING
DIAGNOSIS
Impaired
tissue (skin)
integrity
related to
altered
circulation
secondary
to malignant
tumor of the
OBJECTIVES
INTERVENTIONS
Short term goal:
At the end of 1
hour of nursing
intervention the
patient and the
patient’s significant
others will be able
to:
 Demonstrates
Independent:
1. Prior assessment of
1. Assessed site of
wound etiology is critical
impaired tissue integrity
for proper identification
and its condition.
of nursing interventions.
2. Assessed
characteristics of
wound, including color,
RATIONALE
2. Redness, swelling, pain,
burning, and itching are
indication of
EVALUATION
Short term goal:
GOAL’S MET
The patient’s significant
others demonstrated
understanding of plan to
heal tissue and prevent
injury and verbalized
understanding to the
health teaching given like
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PREOPERATIVE NURSING CARE PLAN
 Affected area is
tender and warm to
touch
 Pain at the left
knee with pain
scale of 8/10
 Guarding
behaviour noted
with facial
grimacing
 Tumor at the left
knee:
 Size
(Cicumference):
15cm
 Color: Black and
and tinged flesh
 Location:
 Odor: Smells like
rotten flesh
 Appearance:
Gangrenous
right knee
understanding
as
of plan to heal
evidenced
tissue and
by damaged
prevent injury
or destroyed  Verbalize
tissue and
understanding
bleeding
to the health
teaching given
like proper
hygienic
practices
 Verbalize DO’s
DON’T’s to
promote
healing of the
wound
Long term goal:
At the end of 16
hour of nursing
intervention the
patient and the
patient’s significant
others will be able
to:
 Reports any
altered
sensation or
size (length, width, and
depth), drainage, and
odor
inflammation and the
body’s immune system
response to localized
tissue trauma.
3. Assessed changes in
3. These findings will give
body temperature,
information on extent of
specifically increased in
injury. Pale tissue color
body temperature.
is a sign of decreased
oxygenation. Odor may
be a result of presence
of infection on the site; it
may also be coming
from a necrotic tissue.
Serous exudate from a
wound is a normal part
of inflammation and
must be differentiated
from pus or purulent
discharge, which is
present in infection.
4. Know the signs of
itching and scratching.
5. Encouraged a diet that
meets nutritional
needs.
6. Encouraged the patient
to avoid rubbing and
proper hygienic practices
And Verbalized DO’s
DON’T’s to promote
healing of the wound
Long term goal:
GOAL’S MET
Patient’s significant
Others was able to
verbalize steps in
performing wound dressing
and verbalize its purpose
and importance.
4. Fever is a systemic
manifestation of
inflammation and may
indicate the presence of
infection.
5. A high-protein, highcalorie diet may be
needed to promote
healing.
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PREOPERATIVE NURSING CARE PLAN
pain at site of
tissue
impairment.
 Know how to
perform wound
dressing and
the importance
of performing
this
scratching. Provide
gloves or clip the nails
if necessary.
6. Rubbing and scratching
can cause further injury
and delay healing.
Dependent:
7. Monitored site of
7. Inadequate nutritional
impaired tissue integrity
intake places the patient
at least once daily for
at risk for skin
color changes,
breakdown and
redness, swelling,
compromises healing.
warmth, pain, or other
signs of infection.
8. Systematic inspection
can identify impending
problems early.
8. Monitored status of skin
around wound.
Monitored patient’s skin
care practices, noting
9. Individualize plan is
type of soap or other
necessary according to
cleansing agents used,
patient’s skin condition,
temperature of water,
needs, and preferences.
and frequency of skin
This technique reduces
cleansing.
the risk for infection.
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PREOPERATIVE NURSING CARE PLAN
9. Kept a sterile dressing
technique during
wound care.
FIFTH PRIORITY: RISK FOR IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS RELATED TO DECREASED FOOD
INTAKE SECONDARY TO LOSS OF APPETITE
CUES/EVIDENCES
NURSING
DIAGNOSI
S
OBJECTIVES
INTERVENTIONS
RATIONALE
EVALUATION
66
PREOPERATIVE NURSING CARE PLAN
Subjective:
Patient’s significant
other verbalizes
“wala gyud na siya
ga kaon ug sakto
maam kay wala
daw siya gana ug
nigamay gyud ni
siya sukad na
higdaay na siya
maam”
Objective:
 Weak in
appearance
 Weight loss
of 10
kilograms
for the last 3
months
 BMI of 20.55
 Poor muscle
tone
 Lack of
interest in
food
Imbalance
nutrition:
less than
body
requirement
s related to
decreased
food intake
secondary
to loss of
appetite
Short term
At the end of 4
hours of nursing
care and
interventions, the
patient’s
significant other
will be able to:
 Verbalize
and know
the foods
that should
be given to
improve
patient’s
weight loss
 Understan
d the
significanc
e of
nutrition to
healing
process
Independent:
1. Ascertained
understanding of
individual
nutritional needs
2. Prevented and
minimized
environmental
unpleasant odor.
3. Cooperated with
family to give and
serve foods that
are likely by the
patient when he’s
already allowed to
eat at the same
time highly rich in
nutrients
4. Taught the about
the proper and
nutritious food
intake
1. To determine
informational need
of the client
Goal met. The patient
was able to verbalized
understanding of the
importance of adequate
nutritional intake
2. May have negative
effect on the
appetite
3. Helps reduce
fatigue during
mealtime, and
provides
opportunity to
increase
respiratory total
caloric intake.
4. Taking nutritious
foods on every
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PREOPERATIVE NURSING CARE PLAN
meal provide
nutrients that the
body needs
68