Traumatic brain injury

Question 1

Signs and symptoms

Answer 1

Confusion
drowsiness
Headache
Limb weakness

Question 2

Aetiology

Answer 2

Close blunt trauma
Concussion
Open brain injury

Question 3

Nursing diagnoses

Answer 3

Risk of pain r/t trauma
Risk of injury to confusion r/t impaired mental state
Risk of neuro complications r/t brain injury

Question 4

Assessments

Answer 4

GCs
Neuro obs
Braden scale

Question 5

Interventions

Answer 5

Record regular changes in GCS
Maintain head and neck alignment
Admin o2 as prescribed

Question 6

Rational For
Record regular changes in GCS
Maintain head and neck alignment
Admin o2 as prescribed

Answer 6

To monitor worsening or progression
To maintain airway patency
To reverse hypoxaemia