Nursing Diagnosis: Disuse Syndrome (includes actual impaired physical mobility, and risks for: impaired skin integrity, constipation, ineffective
peripheral tissue perfusion, and injury) r/t unconsciousness secondary to brain injury AEB immobility, no conscious control of body movements, and
therefore cannot deliberately change positions, protect his body, perform toileting or ADL’s. (Carpenito-Moyet, 2008, p. 146)
Assessment
(client has)
Unconscious
state
Expected Outcomes: The
Client will:______
Will not experience
consequences of
immobility:
Immobility
i. Maintain intact skin
No conscious
control of body
movements
Interventions: (nurse does)
Rationale (because)
Turn q 1-2 hrs, observe for
erythema and blanching, keep
skin dry of sweat, urine, or
stool, use pillows to prop on
side, also to bridge
extremities, cushion bony
prominences, float heels,
position body in alignment.
All prevent skin breakdown, especially
on dependent areas and bony
prominences (Berman, Snyder, Kozier
& Erb, 2008 p. 905, 1222)
Place rolled towels under
palms to prevent contractures.
Prevents shortening of unused or tensed
muscles (Berman, Snyder, Kozier &
Erb, 2008 p. 1118)
Incr proteins and carbs and
maintain serum albumin
Monitor with pre-albumin
level on admit and weekly
Hypoproteinemia increases dependent
edema and thereby skin breakdown,
malnutrition removes padding btwn
skin and the bones (Berman, Snyder,
Kozier & Erb, 2008 p. 905)
Why is pre-albumin tracked?
Boots flex the foot to prevent foot drop
and also float the heels (Berman,
Snyder, Kozier & Erb, 2008 p. 1118)
ii. No foot drop
Apply heel float boots as
ordered – but be careful no
pressure is applied by boots
iii. No loss of ROM
ROM exercises are
contraindicated for this pt at
this time
iv. No DVT
Apply SCD’s as ordered
Stimulation causes excessive cerebral
blood flow/dilation of blood vessels,
IICP, and hypoxia (Ulrich & Canale,
2005 p. 251)
SCD’s move otherwise static, pooling
blood in immobile legs to prevent DVT
(Berman, Snyder, Kozier & Erb, 2008
Evaluation (did EO
happen?)
i. Maintain intact skin:
met
ii. No foot drop: unmet,
pt has foot drop in L
foot
iii.
No loss of ROM:
partially met, seems
to have no loss of
ROM ? how
monitored with
posturing? except in
case of L foot drop
p. 1118, 1417)
v. Have daily bowel
movements
Administer stool softeners
and laxatives as ordered
vi. No injury from posturing
[falling out of bed,
extubating self]
Maintain regular bowel movements
(Wilson, Shannon, Shields, & Stang,
2008).
iv.
No DVT: met: pt
has no signs of
redness, heat, uneven
leg circumferences or
swelling to indicate
DVT
v. Have daily bowel
movements: met
Pt cannot control body movements and
posturing could lead to injury.
Injury precautions: 2 siderails
up. During posturing, guard
invasive lines and ETT
from pt’s hands.
vi.
No injury from
posturing [falling out
of bed, extubing self]:
met.
Collaborative Diagnosis: Ineffective cerebral tissue perfusion r/t temporal cephalhematoma, bilat subdural hemorrhage, subarachnoid
hemorrhage, possible shearing injury [from rapid decel or rotation during crash,] and possible ventricular hemorrhage with increased cerebral
edema AEB unconsciousness, decorticate and decerebrate posturing, respiratory failure. (Ulrich & Canale, 2005, p. 244).
Assessment
(client has)
Unconscious,
non-responsive
state
Decorticate and
decerebrate
posturing
Expected Outcomes: The
Client will:______
Client will have cerebral
tissue perfusion maintained
and optimized per SRMH
TBI protocol:
Abnormal vital
signs – give
details here
Rationale (because)
a. Maintain patent airway and i.
ventilation, keep SpO2 to
100%
SaO2 is on ABG; SpO2 is
pulse oximetry
Enhance O2 supply for cerebral
oxygenation (Wagner, Johnson, &
Kidd, 2006, p. 487). Hypoxia is an
arteriolar cerebrovascular dilator,
causing IICP (Brasher, 2008.)
ii.
Prevent IICP: promote adequate
cerebral venous drainage (Ulrich &
Canale, 2005 p. 250)
Evaluation (did
EO happen?)
1. SaO2 @ 100%:
met.
2. pbtO2 >20mmHg:
met.
1. SaO2 @ 100%
2. pbtO2 >20mmHg
Respiratory
failure
Interventions: (nurse does)
3. ICP <20 mmHg
b.HOB to 30, head in midline,
no flexion/ extension of
neck.
iii.
4. Optimize CPP, target >60 c. Schedule care so that harsh
activity [suctioning bathing,
5. Keep temp 36-37c
turning] are not grouped
(SRMH Protocol, 2008 p. 4)
together, with breaks btwn
care for recovery. Talk
Because this is by protocol
softly and limit touch and
these values are permitted
stimulation.
as expected outcomes
iv.
d.Admin laxatives,
antitussives and antiemetics
as ordered
Prevent incr intrathoracic pressure
which impedes venous return from
the brain (IICP) (Ulrich & Canale,
2005 p. 250)
4. Optimize CPP,
target >60:
unmet, CPP
below 60 after
period of
prolonged
intense
stimulation with
minimal pain
medication.
v.
5. Keep temp 3637c: partially
met: temp was
Prevent incr metabolic rate, excessive
above 37 [37 to
dilation of cerebral blood vessels,
37.7] during two
IICP, and subsequent hypoxia (Ulrich
shifts.
& Canale, 2005 p. 251)
vi.
same as previous
vii.
Osmotic diuretic that draws fluid
e. Control pain w/ opiates and
sedate with benzodiazepines
as ordered
f. Manage temp w/
antipyretics and cooling
Stimulation causes excessive cerebral
blood flow/dilation of blood vessels,
IICP, and hypoxia (Ulrich & Canale,
2005 p. 251)
3. ICP <20 mmHg:
met.
measures. Prevent seizure
w/ ordered dilantin.
g.Admin mannitol 25-50 g IV
bolus if ICP >20. (SRMH viii.
Protocol, 2008 p. 4)
Monitor sodium level and
collaborate with MD if high
h.Drain CSF via
ix.
ventriculostomy if ICP >20
(SRMH Protocol, 2008 p. 4)
from cerebral interstitium and
decreases ICP (Ulrich & Canale,
2005 p. 250)
Less CSF means less fluid in the
cerebral compartment therefore
lowers ICP (Wagner, Johnson, &
Kidd, 2006, p. 422).
Low pCO2 produces vasoconstriction
and can decrease IICP, but has longterm deleterious effects. (Wagner,
Johnson, & Kidd, 2006, p. 421)].
i. Titrate PaCO2 through
therapeutic hyperventilation
to balance ICP <20mmHg x.
and pbtO2 >20 (SRMH
Protocol, 2008 p. 4), but do
not use long-term.
Collaborate with RT
IFV increases volume, therefore
MAP and CPP, vasopressors
vasoconstrict to increase blood
pressure and CPP (Wagner, Johnson,
& Kidd, 2006, p. 421).
j. Give IVF, then start
vasopressors as ordered
[dopamine, phenylephrine, xi.
epinephrine, and/or
norsynephrine] if pbtO2 <20
mmHg (SRMH Protocol,
2008 p. 5)
Low Hct with affected pbtO2 means
there is insufficient carrying capacity
of O2 which PRBCs will supplement
(Leeuwen, Kranpitz, & Smith, 2006,
p 1136)
k.Give PRBCs if Hct < 30 andxii. Shivering causes an incr metabolic
pbtO2 <20 (SRMH
rate, excessive dilation of cerebral
Protocol, 2008 p. 5)
blood vessels, IICP, and subsequent
hypoxia (Wagner, Johnson, & Kidd,
2006, p. 421)
l. If shivering, consider
paralytic (SRMH Protocol,
2008 p. 5)