Head Injury Nursing Diagnosis and Nursing Care Plan - NurseStudy.Net (2023)

Head Injury Nursing Diagnosis and Nursing Care Plan - NurseStudy.Net (1)

Head Injury Nursing Care Plans Diagnosis and Interventions

Head Injury NCLEX Review and Nursing Care Plans

Any concussion to the brain, skull, or scalp is considered a head injury. A traumatic brain injury can range from a minor bump or bruise to severe head trauma.

The implications and therapeutic interventions differ tremendously depending on what caused the head injury and its severity.

There are two common kinds of head injuries: closed and open.

Any head injury that does not damage the skull is referred to as a closed head injury.

An open (penetrating) head injury occurs when something permeates the scalp and skull, entering the brain.

It is hard to ascertain how severe a head injury is just by looking at it. Some minor head injuries bleed profusely, while others do not bleed at all.

All head injuries should be addressed medically and evaluated by a physician.

Types of Head Injury

  1. Hematoma. A hematoma is a blood clot formation outside the blood vessels. A hematoma in the brain can be incredibly dangerous. Pressure can build up inside the skull as a result of the clotting. It is indeed possible that the patient may lose consciousness or suffer permanent neurological damage.
  1. Hemorrhage. Uncontrolled bleeding is referred to as a hemorrhage. Subarachnoid hemorrhage is bleeding in the space around the brain, while intracerebral hemorrhage is bleeding within the brain tissue. Moreover, headaches and nausea are common symptoms of subarachnoid hemorrhages. The amount of bleeding measures the intensity of intracerebral hemorrhages, but any volume of blood can end up causing fluid to accumulate over time.
  1. Concussion. When an impact to the head is strong enough to cause brain trauma, it is called a concussion. A concussion transpires when the brain collides with the skull’s formidable walls or by sudden acceleration and deceleration forces. In most cases, the impairment of body functions caused by a concussion is only temporary. Multiple concussions, on the other hand, can cause irreversible damage.
  1. Edema. Also known as swelling, edema can result from any brain injury. Swelling of the surrounding tissues is joint in many injuries, but it is hazardous in the brain. As a result, the affected person cannot stretch the skull to accommodate the swelling. Edema leads to the accumulation of pressure in the brain, causing it to press against the skull.
  1. Fracture of the skull. Dissimilar to other bones in the body, the skull lacks bone marrow. As a result, the skull is highly resilient and tough to break. Since a broken skull cannot absorb the force of a blow, it is more highly probable that the brain will be damaged as well.
  1. Diffuse axonal injury. A diffuse axonal injury, commonly known as sheer injury, is a type of brain injury that does not result in hemorrhage but damages cells in the brain. Since the brain cells are severely damaged, they cannot function effectively. It can also lead to inflammation, aggravating the situation. Furthermore, a diffuse axonal injury is one of the most threatening head injuries. Thus, even though this is not as noticeable as other types of brain injury, it has a higher possibility to cause irreparable brain damage, as well as fatality.

Signs and Symptoms of Head Injury

Since the head has more blood vessels than any other part of the body, bleeding on the surface or within the brain during a head injury is a significant concern. However, not all head injuries result in bleeding.

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The following are common symptoms of a minor head injury:

  • Dizziness
  • Migraine
  • Mild disorientation
  • Temporary ringing in the ears
  • Whirling sensation
  • Vertigo

Many of the symptoms of a severe head injury are similar to those of a minor head injury. They may also include the following:

  • State of unconsciousness
  • Convulsions
  • Vomiting
  • Balance or coordination impairment
  • Severe confusion
  • Inability to focus one’s eyes for a moment
  • Unusual eye movements
  • Deterioration in muscle control
  • Headache that persists or worsens
  • Memory lapses
  • Alterations in mood
  • Clear fluid leaking from the ear or nose

Causes of Head Injury

The following are the most common causes of head injuries:

  • Violent behavior
  • Accidents involving cars or motorcycles
  • Child abuse
  • Fall incidents

When two athletes collide, or a player was hit in the head with a piece of sporting equipment, a concussion or other head injury can also occur.

As a result, the following sports-related activities cause the most significant number of head injuries in people of all ages:

  • Riding powered recreational vehicles such as dune buggies, go-karts, and mini bikes
  • Cycling
  • Softball and baseball
  • Basketball
  • Football

Head injuries are not always the result of sports or trauma. Other causes of concussions or brain hemorrhages include:

  • Bleeding disorders such as Hemophilia
  • Improper usage of blood thinners or certain recreational drugs
  • Long-term hypertension (in adults)

Risks Factors to Head Injury

The following groups are the most vulnerable to traumatic brain injury:

  • Children, particularly newborn babies to four-year-olds
  • Young adults, particularly those aged 15 to 24,
  • Adults aged 60 and up
  • Males of any age are eligible.

Diagnosis of Head Injury

  • Glasgow Coma Scale (GCS) – This 15-point test assists a doctor, or other urgent care personnel in determining the initial intensity of a brain injury by assessing a person’s ability to follow commands and the movement of their eyes and limbs. The consistency of speech also gives valuable data. The Glasgow Coma Scale rates abilities on a scale of three to fifteen. Higher scores indicate less severe injuries.
  • Patient Interview – Evaluating the details about the injury and its symptoms. The answers to the following questions may be critical in identifying the intensity of the head injury:
  • What caused the head injury?
    • Did the individual pass out?
    • How long was the individual unconscious?
    • Did someone notice any other changes in alertness, speech, coordination, or other signs of the patient’s injury?
    • What parts of the body, if any, were struck?
    • Provide necessary information about the severity of the injury. For instance, what struck the person’s head, how far did he or she fall, or was the person thrown from a vehicle?
    • Was the individual’s body thrown around or grievously shaken?
  • Imaging tests
    • Computerized Tomography (CT scan). This test is performed in an emergency room for a suspected traumatic brain injury. A CT scan creates a detailed image of the brain using a sequence of X-rays. A CT scan can accurately identify fractures as well as proof of internal bleeding (hemorrhage), blood clots (hematomas), lacerated brain tissue (contusions), and inflammation of brain tissue.
    • Magnetic Resonance Imaging (MRI). An MRI provides a comprehensive image of the brain using powerful radio waves and magnets. This test is beneficial once the patient’s condition has stabilized or if clinical manifestations do not rectify within a few days of the injury.

Treatment for Head Injury

  1. Medications. The following medications are used to treat various types of head injuries:
  • Anti-seizure medication – may be prescribed within the first week of treatment to prevent any additional brain damage inflicted by a seizure. Seizures are only treated with anti-seizure medications as long as they occur.
  • Coma-inducing medications – used to induce momentary comas since an unconscious brain requires less oxygen to function. This medication is incredibly beneficial if blood vessels in the brain are constricted by tremendous pressure and cannot deliver average amounts of essential nutrients and oxygen to brain cells.
  • Diuretics – decrease the amount of fluid in the body tissue while increasing urine output. Diuretics minimize pressure within the brain if administered intravenously to people suffering from brain trauma.
  1. Surgery. Surgery may be an excellent choice to treat the following health issues:
  • Removal of coagulated blood (hematomas) – Hemorrhage from the outside or inside the brain can cause blood clot collection, putting much pressure on the brain and damaging brain tissue.
  • Repair of fracture/s in the skull – Surgery may be required to fix severe skull fractures or remove skull fragments from the brain.
  • Cessation of bleeding in the brain – Head trauma that results in brain hemorrhage may necessitate surgery to cease the bleeding.
  • Reduction of intracranial pressure (ICP) – Surgery may alleviate the pressure within the skull by depleting aggregated cerebrospinal fluid in the brain.

3. Rehabilitation. The majority of people who have suffered substantial brain trauma will need rehabilitation. They may need to relearn essential skills like walking and talking. The focus of rehabilitation is to enhance their ability to carry out daily tasks.

Prevention of Head Injury

Depending on the extent of damage, brain injury symptoms can be minor, tolerable, or severe. Sometimes even minor injuries can affect how the brain functions. Follow these prevention tips to lower the risk of traumatic brain injury:

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  • Put on the seat belt all the time when driving.
  • Do not drive while intoxicated in liquor or drugs.
  • Avoid using a cellular phone while driving.
  • Always put on a helmet while riding a motorcycle.
  • Perform actions to prevent slips and falls at home.
  • Take good care of children to avoid head injuries at all costs.

Nursing Diagnosis for Head Injury

Nursing Care Plan for Head Injury 1

Risk for Bleeding

Nursing Diagnosis: Risk for Bleeding related to tissue trauma or disturbance of the standard blood clotting mechanisms secondary to head injury as evidenced by petechiae, bruises, blood clot formation, or overflowing of blood.

Desired Outcome: The patient will learn how to prevent bleeding and recognize clinical manifestations of hemorrhage that must be disclosed to a health care professional instantaneously.

Nursing Interventions for Head InjuryRationale
Instruct the at-risk patient on how to take precautions to avoid tissue trauma or disruption of standard clotting mechanisms. The knowledge of safety precautions minimizes the incidence of bleeding.
Inform the patient and family members on the manifestations of bleeding that must be disclosed to a health care provider right away. The earlier a health care provider evaluates and treats bleeding, the lower the associated complications from blood loss.
Advise the female patient that an increase in menstrual periods, as indicated by an increase in the number of sanitary pads used, should be mentioned to the healthcare professional. Changes in blood clotting may result in higher blood loss during regular menstruation.
Inform the patient and family members about the health hazards of using natural supplements that have been associated with a higher likelihood of hemorrhage. A large percentage of herbal remedies impede platelet activation by inhibiting serotonin release from the platelet. Other herbs enhance the impact of antiplatelet and anticoagulant medications, raising the risk of bleeding.
Instruct family and friends to participate in decision-making regarding the diagnosis and treatment of who is at risk for bleeding complications. Full engagement of the family and friends promotes a better comprehension of the rationale and adherence to the intervention.

Nursing Care Plan for Head Injury 2

Acute Confusion

Nursing Diagnosis: Acute Confusion related to a pattern of memory impairment secondary to head injury as evidenced by changes in cognition, heightened agitation, or alterations in one’s level of consciousness.

Desired Outcome: The patient will have diminished hallucinations and recover normal reality orientation and consciousness.

Nursing Interventions for Head InjuryRationale
Determine the presence of risk factors such as substance misuse, seizure episodes, current Electroconvulsive Therapy (ECT) therapy, incidents of fever/pain, the presence of acute infection, especially urinary tract infection in elderly patients, exposure to potentially harmful substances, traumatic experiences, and changes in the external environment such as unfamiliar noises and excessive visitors. This intervention is beneficial since baseline data aids in developing a specific plan.
Sustain a regular sleep-wake cycle for the patient as possible. For example, avoid allowing the patient to nap during the day, avoid trying to wake patients at night, give tranquilizers but not diuretics prior to sleep, and provide pain medicine and sensual massages. The sleep-wake cycle is disrupted in people who have acute confusion. As a result, this approach will assist the patient in resuming a typical sleeping pattern. Carry out a thorough mental health examination that includes the following: Overall appearance, mannerisms, and personalityEvaluation of behavior, attitude, and level of motor coordinationMood and affect (the existence of suicidal or homicidal thought patterns as witnessed by others and disclosed by the patient)Interpretation and decision-making capabilitiesLevel of consciousness, orientation (to time, place, and person), way of thinking, and content are all indicators of cognition.Attention An excellent diagnostic feature of delirium is confused thinking. Delirium is a mental state, whereas agitation is a behavioral symptom. Some patients may be delirious without being agitated and may exhibit withdrawn habits. These symptoms manifest a type of delirium that is hypoactive. However, some patients have delirium that is both hypoactive and hyperactive. Therefore, this approach is beneficial in assessing the patient’s mental health status.
As necessary, ensure the patient’s cognitive performance systematically and regularly during the day and night. Delirium always involves an acute change in mental status; consequently, recognizing the patient’s benchmark mental status is crucial for determining delirium.
Examine the degree of impairment in orientation, ability to focus, capacity to grasp directions, send or receive communication, and response appropriateness. This approach should be conducted to identify the severity of the impairment.

Nursing Care Plan for Head Injury 3


Nursing Diagnosis: Nausea related to acute concussion secondary to head injury as evidenced by headache and vomiting.

Desired Outcome: The patient will report a reduction in the intensity or complete elimination of nausea.

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Nursing Interventions for Head InjuryRationale
Make an emesis basin easily accessible to the patient. Vomiting and nausea are directly connected. If the nausea is psychogenic, keep the emesis basin out of sight but still within reach of the patient.
Allow the patient to utilize non – pharmacologic nausea management techniques such as resting, mental imagery, music education, diversionary tactic, or deep breathing techniques. These techniques have assisted patients in resolving the condition, but they must be used before it occurs.
Analyze the patient’s response to antiemetics or other treatments to alleviate the condition. This method is essential for evaluating the efficacy of such interventions.
Teach the patient or nurse how to use accu-stimulation bands or acupressure. If the intervention was beneficial and practical, patients and nurses might intend to continue with it.
Educate the patient on the significance of shifting positions slowly and gently. Excessive or erratic movement may exacerbate the condition.

Nursing Care Plan for Head Injury 4

Acute Pain (Headache)

Nursing Stat Facts

Nursing Stat Facts

Nursing Diagnosis: Acute Pain related to traumas and illnesses secondary to head injury as evidenced by severe migraine.

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Desired Outcome: The patient will be able to cope with acute pain.

Nursing Interventions for Head InjuryRationale
Understand and acknowledge the patient’s pain. Nurses have a responsibility to question their patients about their pain and to presume their patients’ reports of pain. Challenging or undermining their pain reports leads to an undesirable therapeutic relationship, impeding pain treatment and degrading rapport.
Nonpharmacologic pain management can be another option to relieve a patient’s pain. Physiological, cognitive-behavioral techniques and lifestyle pain management are nonpharmacologic pain control strategies.
Examine the effectiveness of painkillers as prescribed and keep an eye out for any clinical manifestations of side effects. Pain medications must be evaluated separately for each patient because they are absorbed and metabolized differently.
Ascertain pain-relieving factors. Ask if the patients have done anything to relieve their pain. Contemplation, breathing techniques, exercises, praying, and other similar practices may be included. Information on these pain-relieving techniques can be incorporated into pain-management planning.
During the peak effect of analgesics, deliver nursing care. Oral painkillers typically reach their full potential in sixty minutes, while intravenous analgesics peak in twenty minutes. When nursing tasks are performed during the maximum effect of analgesics, client comfort and compliance in care are maximized.

Nursing Care Plan for Head Injury 5

Risk for Seizure

Nursing Diagnosis: Risk for Seizure related to unwanted electrical firing or discharges from cerebral cortex nerve fibers secondary to head injury as evidenced by short, brief episodes of altered state of consciousness, motor functions, and sensory manifestations.

Desired Outcome: The patient will execute safety measures when seizure episodes occur suddenly.

Nursing Interventions for Head InjuryRationale
Investigate and explain seizure warning signs as well as the typical seizure pattern. Educate the family on how to acknowledge and recognize warning signs and how to care for the patient during and after seizure episodes. This intervention allows the patient to guard himself against harm and recognize disturbances that require notification of the physician and further intervention. Understanding what to do if a seizure happens can prevent injury or complications and reduce a patient’s feelings of helplessness.
Do not leave patients while he or she is experiencing seizure symptoms. This approach encourages safety precautions.
Reorient the patient after seizure attacks. After the seizure, the patient may be bewildered, disorganized, and potentially amnesic and require assistance to regain control and relieve anxiety.
Examine the patient’s reports of pain. Pain could result from repetitive muscle contractions or a clinical sign of an injury that necessitates further assessment or treatment.
Instruct the patient not to smoke unless carefully monitored. If a cigarette is dropped unintentionally during aura or seizure activity, it may lead to burns.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020).Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon

Gulanick, M., & Myers, J. L. (2017).Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018).Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon

Silvestri, L. A. (2020).Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon


Please follow your facilities guidelines, policies, and procedures.

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The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

Head Injury Nursing Diagnosis and Nursing Care Plan - NurseStudy.Net (2)


What is the nursing care for head injury? ›

Maintain airway and ventilation. Maintain cerebral perfusion pressure. Prevent secondary injuries (by recognizing and treating hypoxia, hypercapnia, or hypoperfusion) Evaluate and manage for increased ICP.

What is the nursing assessment for head injury? ›

Assessment of the head injury patient should include airway, cervical spine protection, breathing, circulation, and haemorrhage control followed by the GCS. The GCS score should be used in the assessment of all patients with head injury by trained healthcare providers.

How do you write a nursing diagnosis for a care plan? ›

A nursing diagnosis has typically three components: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics or risk factors (for risk diagnosis). BUILDING BLOCKS OF A DIAGNOSTIC STATEMENT. Components of an NDx may include problem, etiology, risk factors, and defining characteristics.

How do you write a nursing diagnosis with Nanda? ›

Nursing diagnoses must include the problem and its definition, the etiology of the problem, and the defining characteristics or risk factors of the problem. The problem statement explains the patient's current health problem and the nursing interventions needed to care for the patient.

What is a nursing diagnosis for concussion? ›

A concussion diagnosis is considered when an individual presents with any of the following signs and symptoms: mental status changes (such as amnesia or confusion), physical signs (such as fatigue, blurred vision, or headache), or behavioral effects (such as irritability or personality changes).

What is the correct nursing intervention when a client with head injury begins to have clear drainage from his nose? ›

If the drainage is clear, the nurse should check it for glucose. The head of the bed should be elevated 15 to 30 degrees to facilitate the drainage and decrease intracranial pressure.

What is the diagnosis for head injury? ›

Diagnosis of TBI

Assessment usually includes a neurological exam. This exam evaluates thinking, motor function (movement), sensory function, coordination, eye movement, and reflexes. Imaging tests, including CT scans and MRI scans, cannot detect all TBIs.

How do you diagnose a head injury? ›

A CT scan can quickly visualize fractures and uncover evidence of bleeding in the brain (hemorrhage), blood clots (hematomas), bruised brain tissue (contusions), and brain tissue swelling. Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and magnets to create a detailed view of the brain.

What is the priority action for head injury? ›

The injured person should lie down with the head and shoulders slightly elevated. Don't move the person unless necessary. Avoid moving the person's neck. If the person is wearing a helmet, don't remove it.

What is a nursing diagnosis example? ›

Examples of nursing diagnosis: risk for impaired liver function; urinary retention; disturbed sleep pattern; decreased cardiac output. On the other hand, a medical diagnosis is made by a doctor or advanced health care practitioner.

Which is the best example of a nursing diagnosis? ›

An example of an actual nursing diagnosis is: Sleep deprivation. Describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community. It is supported by risk factors that contribute to increased vulnerability. An example of a risk diagnosis is: Risk for shock.

How do you write a care plan example? ›

Every care plan should include:
  1. Personal details.
  2. A discussion around health and well being goals and aspirations.
  3. A discussion about information needs.
  4. A discussion about self care and support for self care.
  5. Any relevant medical information such as test results, summary of diagnosis, medication details and clinical notes.
Feb 14, 2022

How do you write a diagnosis statement? ›

Diagnostic statements should begin with the patient's activities and participation restrictions and how they relate to the patient's impairments and medical diagnosis.

What is an example of an actual diagnosis? ›

Actual diagnosis - a statement about a health problem that the client has and the benefit from nursing care. An example of an actual nursing diagnosis is: Ineffective airway clearance related to decreased energy as manifested by an ineffective cough.

What is the nursing diagnosis for dizziness? ›

There is another medical term for dizziness which is vertigo or BPPV (benign paroxysmal position al vertigo), a medical diagnosis in which a patient common experiences a spinning sensation inside their head which can be accompanied by nausea or vomiting which can be a sign of it.

What are the 4 types of nursing diagnosis *? ›

There are 4 types of nursing diagnoses: risk-focused, problem-focused, health promotion-focused, or syndrome-focused.

What is a Nanda diagnosis risk for injury? ›

According to Nanda the definition of risk for injury is the state in which an individual is at risk for harm because of a perceptual or physiologic deficit, a lack of awareness of hazards, or maturational age.

Can nurses make nursing diagnosis? ›

A nurse making a diagnosis must be working under strict protocol or direct supervision of a physician. Any other diagnosis made by a nurse constitutes the unauthorized practice of medicine. The term nursing diagnosis is often used as the title of a nursing care plan.

What is the goal of nursing management of the patient with a head injury? ›

The primary goal of nursing management in severe head trauma is to maintain adequate cerebral perfusion and improve cerebral blood flow in order to prevent cerebral ischaemia and secondary injury to the brain.

What is the most important thing to do in treating a patient with a head injury and spinal cord injury? ›

Call 911 or emergency medical help. Keep the person still. Place heavy towels or rolled sheets on both sides of the neck or hold the head and neck to prevent movement. Avoid moving the head or neck.

What is the observation of head injury? ›

Signs include clear fluid running from the ears or nose, black eye with no associated damage around the eyes, bleeding from one or both ears, bruising behind one or both ears, penetrating injury signs, visible trauma to the scalp or skull of concern to the professional.

What are 3 most common head injuries? ›

The following are some of the different types of head injuries:
  • Concussion. A concussion is an injury to the head area that may cause instant loss of awareness or alertness for a few minutes up to a few hours after the traumatic event.
  • Skull fracture. ...
  • Intracranial hematoma (ICH).

What are the 4 signs of head injury? ›

Signs of a brain injury after a head injury include:
  • unconsciousness – either brief (concussion) or for a longer period of time.
  • fits or seizures.
  • problems with the senses – such as hearing loss or double vision.
  • repeated vomiting.
  • blood or clear fluid coming from the ears or nose.
  • memory loss (amnesia)
Apr 1, 2021

What are 5 signs & symptoms of a traumatic head or brain injury? ›

Physical symptoms
  • Loss of consciousness from several minutes to hours.
  • Persistent headache or headache that worsens.
  • Repeated vomiting or nausea.
  • Convulsions or seizures.
  • Dilation of one or both pupils of the eyes.
  • Clear fluids draining from the nose or ears.
  • Inability to awaken from sleep.
Feb 4, 2021

What happens in a head injury assessment? ›

This off- field screening tool includes a check of symptoms, memory assessment and balance evaluation. Only used in the professional game, the results of this off-field assessment are compared to a previously conducted 'baseline assessment', or to a normative result.

Which test is most diagnostic for identifying head injuries? ›

A CT (or “CAT”) scan takes X-rays from many angles to create a complete picture of the brain. It can quickly show whether the brain is bleeding or bruised or has other damage. Magnetic resonance imaging (MRI). MRI uses magnets and radio waves to produce more detailed images than CT scans.

What are 3 ways to prevent head injury? ›

You Can Prevent Traumatic Brain Injury
  • Buckle Up Every Ride – Wear a seat belt every time you drive – or ride – in a motor vehicle.
  • Never drive while under the influence of alcohol or drugs.
  • Wear a helmet, or appropriate headgear, when you or your children: ...
  • Prevent Older Adult Falls.

How should you treat a head injury? ›

Keep the head in line with the spine and prevent movement. Wait for medical help. Stop any bleeding by firmly pressing a clean cloth on the wound, unless you suspect a skull fracture. If the injury is serious, be careful not to move the person's head.

What are 4 ways that we can prevent head injuries? ›

How to Prevent Head Injuries
  • Wear your seat belt. ...
  • Don't drive under the influence of drugs or alcohol. ...
  • Don't text or use a cell phone while driving. ...
  • Wear a helmet. ...
  • Prevent falls at home. ...
  • Prevent head injuries in children.

What is a 3 part nursing diagnosis statement? ›

A nursing diagnosis generally has three components: a diagnosis approved by NANDA-I, a related to statement which defines the cause of the NANDA-I diagnosis, and an as evidenced by statement that uses specific patient data to provide a reason for the NANDA-I diagnosis and related to statement.

What is the nursing diagnosis priority order? ›

Nurses should apply the concept of ABCs to each patient situation. Prioritization begins with determining immediate threats to life as part of the initial assessment and is based on the ABC pneumonic focusing on the airway as priority, moving to breathing, and circulation (Ignatavicius et al., 2018).

What is risk for injury as evidenced by? ›

risk for Injury/Trauma is possibly evidenced by risk factors of inability to recognize or identify danger in environment, disorientation, confusion, impaired judgment, weakness, muscular incoordination, balancing difficulties, altered perception, seizure activity.

How do you write a simple nursing care plan? ›

Here's a step-by-step breakdown of how to write a nursing care plan with a sample patient: Casey Clarke.
  1. Step 1: Assess the Patient.
  2. Step 2: Sort Out a Diagnosis.
  3. Step 3: Plan Patient Goals and Desired Outcomes.
  4. Step 4: Compile an Evaluation.
  5. Step 5: Write it All Out.
Jul 22, 2022

How do you write a diagnosis summary? ›

It should always include the following: (1) a discussion on the diagnosis (2) aetiological factors, which seem important, as well as taking into account (3) the patient's life situation and background, with (4) a plan for treatment and (5) an estimate of the prognosis.

What are the 3 steps in diagnosis? ›

The diagnostic process involves multiple steps: Take a medical history. Perform a physical exam. Order diagnostic testing.

What is a diagnosis summary? ›

diagnosis, Identification of a disease or disorder. Diagnosis requires a medical history (including family history), a physical examination, and usually tests and diagnostic procedures (e.g., blood analysis, diagnostic imaging).

What are the 3 types of diagnosis? ›

Sub-types of diagnoses include: Clinical diagnosis. A diagnosis made on the basis of medical signs and reported symptoms, rather than diagnostic tests. Laboratory diagnosis.

What is basic diagnosis? ›

The steps of the diagnostic process fall into three broad categories: Initial Diagnostic Assessment – Patient history, physical exam, evaluation of the patient's chief complaint and symptoms, forming a differential diagnosis, and ordering of diagnostic tests.

What is the patient's diagnosis? ›

The process of identifying a disease, condition, or injury based on the signs and symptoms a patient is having and the patient's health history and physical exam. Further testing, such as blood tests, imaging tests, and biopsies, may be done after a clinical diagnosis is made.

What is the diagnosis for dizziness? ›

The patient history can generally classify dizziness into one of four categories: vertigo, disequilibrium, presyncope, or lightheadedness. The main causes of vertigo are benign paroxysmal positional vertigo, Meniere disease, vestibular neuritis, and labyrinthitis.

What is the nursing diagnosis for weakness? ›

Common Signs and Symptoms of Activity Intolerance

Symptoms of activity intolerance may include the following: Reports of weakness or fatigue. Altered physiologic response to activity. Inability to perform or endure desired activities (e.g., verbal reports of weakness).

What is the nursing diagnosis for fatigue? ›

Fatigue is a subjective complaint with both acute and chronic conditions. It is the self-recognized state in which an individual experiences an overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work that is not relieved by rest.

How do you care for a head injury patient? ›

Administer the following first-aid steps while waiting for emergency medical help to arrive:
  1. Keep the person still. The injured person should lie down with the head and shoulders slightly elevated. ...
  2. Stop any bleeding. ...
  3. Watch for changes in breathing and alertness.

How do you treat a head injury patient? ›

If your child experiences a knock, bump or blow to the head, sit them down, comfort them, and make sure they rest. You can hold a cold compress to their head – try a bag of ice or frozen peas wrapped in a tea towel. Seek immediate medical advice if symptoms such as mild dizziness and a headache get worse.

What are the major responsibilities of a head nurse? ›

A Head Nurse responsible for the overall care of patients seeking treatment at an outpatient & In Patient medical facility. It is the responsibility of the Head nurse to manage the team and ensure the comfort of patients before, during and after medical procedures and surgery.

What is the goal of caring for a patient with a head injury? ›

Emergency care for moderate to severe traumatic brain injuries focuses on making sure the person has enough oxygen and an adequate blood supply, maintaining blood pressure, and preventing any further injury to the head or neck.

What are the 3 main types of head injury? ›

What are the different types of head injury?
  • Concussion. A concussion is an injury to the head area that may cause instant loss of awareness or alertness for a few minutes up to a few hours after the traumatic event.
  • Skull fracture. A skull fracture is a break in the skull bone. ...
  • Intracranial hematoma (ICH).

What are 3 signs of a head injury? ›

Physical symptoms
  • Loss of consciousness from several minutes to hours.
  • Persistent headache or headache that worsens.
  • Repeated vomiting or nausea.
  • Convulsions or seizures.
  • Dilation of one or both pupils of the eyes.
  • Clear fluids draining from the nose or ears.
  • Inability to awaken from sleep.
Feb 4, 2021

What are the 5 classification of head injury? ›

Head injuries may be categorized in several ways. Injuries are classified by mechanism (closed vs. penetrating injury), morphology (fractures, focal intracranial injury and diffuse intracranial injury), and severity (mild, moderate and severe).

What should you not do after a head injury? ›

Avoid activities that are physically demanding (e.g., heavy houscleaning, weightlifting/working-out) or require a lot of concentration (e.g., balancing your checkbook). They can make your symptoms worse and slow your recovery.

When should you treat a head injury? ›

Seek Immediate Medical Attention, If Any of the Following Symptoms Occur:
  1. Repeated vomiting.
  2. Worsening or severe headache.
  3. Unable to stay awake during times you would normally be awake.
  4. Very drowsy or cannot be awakened.
  5. One pupil (the black part in the middle of the eye) larger than the other.
  6. Convulsions or seizures.

What are 3 responsibilities of a nurse? ›

Key Responsibilities
  • Perform physical exams and health histories before making critical decisions.
  • Provide health promotion, counseling and education.
  • Administer medications and other personalized interventions.
  • Coordinate care, in collaboration with a wide array of health care professionals.

What are the 4 fundamental responsibilities of nurses? ›

Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering. The need for nursing is universal. Inherent in nursing is a respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect.


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