Traumatic Brain Injury (TBI) Nursing Diagnosis & Care Plan

Traumatic brain injury (TBI) is a serious form of head injury that causes damage to the brain resulting from an external mechanical force. This condition can result in temporary and permanent impairment in sensory perception, cognition, mobility, or psychosocial function. 

Major causes of TBI include falls, assault, motor vehicular accidents, and injuries causing a blow to the head. This condition may be categorized as mild to moderate causing a brief change in consciousness or severe causing prolonged unresponsiveness, coma, or death. 

Damages occurring due to TBI are often described as primary or secondary. Primary injury is associated with the direct effects of trauma on the skull and brain at initial impact. Secondary injury refers to the complications arising hours to days later from dysfunction and pathophysiological changes of the brain tissue like infection, increased intracranial pressure, and hypoxemia. 

Patients with TBI often exhibit external signs of head trauma like lacerations, bleeding, and ecchymosis. The patient’s level of consciousness may be affected and changes in pupil shape, size, and reactivity or a decrease in the Glasgow coma scale (GCS) require immediate intervention. Changes in the patient’s vital signs can indicate increased ICP. 

The signs and symptoms of mild TBI include headache, dizziness, drowsiness, balance disturbance, nausea and vomiting, and impaired cognitive and emotional state. Patients with severe TBI can display hemiplegia, flexor or extensor posturing, language deficits, behavioral and cognitive changes, and hemiparesis.

Computed tomography (CT) scan is often ordered to rapidly identify areas of developing hematomas that require immediate intervention. Additionally, magnetic resonance imaging (MRI) is indicated if brain stem and vascular injury are suspected. 

The Nursing Process

Management of TBI varies depending on the severity of the injury. The management of patients with mild TBI includes neurologic assessment as well as patient education about post-concussive symptoms like irritability, fatigue, headache, and sleep disturbances. While in most cases, the symptoms of mild TBI will resolve, an evaluation by a specialist may be needed for persistent symptoms. 

The management of moderate to severe TBI is focused more on the optimization of functional recovery through minimizing secondary brain injury. 

Nursing responsibilities in the treatment of patients with TBI will not only involve patient education and meticulous physical and neurologic assessment and monitoring but also interventions that will support cerebral perfusion and prevent ischemia.

Nursing Care Plans Related to Traumatic Brain Injury 

Ineffective Cerebral Tissue Perfusion 

Patients with TBI are susceptible to a decrease in cerebral tissue perfusion. As a result of brain injury, there may be swelling, bleeding, or CSF leaking affecting perfusion. Increased ICP occurs when the brain is not able to accommodate further volume changes, resulting in decreased cerebral perfusion, brain tissue ischemia, and edema. If cerebral edema is left untreated, the brainstem will herniate downward causing irreversible brain damage and death.

Nursing Diagnosis: Ineffective Tissue Perfusion

Related to:

  • Hemorrhage
  • Skull fractures
  • Cerebral edema (localized or generalized response to injury)
  • Decreased systemic blood pressure
  • Hypoxia

As evidenced by:

  • Mental status changes
  • Decreased LOC
  • Pupillary changes
  • Changes in motor response
  • Difficulty swallowing or speaking

Expected Outcomes:

  • The patient will maintain an expected level of consciousness, motor response, sensory function, and cognition. 
  • The patient will display adequate perfusion as evidenced by stable vital signs and hemodynamics.

Ineffective Cerebral Tissue Perfusion Assessment

1. Assess and obtain an accurate patient history.
Obtaining an accurate history from the patient suffering from TBI may be difficult depending on the severity of the brain injury. It can be obtained from witnesses of the injury or the first responders. It is essential to ask when, where, and how the injury occurred as this will help plan and formulate the most appropriate treatment regimen.

2. Assess and monitor neurological status frequently.
Changes in the patient’s level of consciousness can indicate complications. Monitoring changes in neurologic status and GCS in patients with TBI is vital because the patient’s condition can deteriorate rapidly, requiring emergency surgery.

3. Assess and monitor vital signs.
The mechanism of autoregulation is impaired following TBI. Severe TBI causes impairment in the function of the cerebral vasculature to modify systemic pressure to ensure sufficient blood flow to the brain. Blood pressure and pulse must be monitored frequently as the patient can exhibit hypotension or hypertension. Cushing’s triad (irregular respirations, widened pulse pressure, and bradycardia), a classic but late sign of increased ICP, indicates imminent brainstem herniation.

4. Evaluate diagnostic studies.
A CT scan is often ordered to identify the extent of the injury. This diagnostic procedure can help identify injuries such as hemorrhage requiring immediate surgical intervention. An MRI may be ordered to diagnose a diffuse axonal injury.

Ineffective Cerebral Tissue Perfusion Interventions

1. Evaluate and monitor pupillary responses.
It is essential to report any changes in pupil size, reactivity, and shape immediately as this can indicate an increase in the patient’s ICP. This assessment can also reveal specific areas of brain damage. Unresponsive pinpoint pupils indicate brainstem dysfunction while asymmetric pupils, dilated pupils, or loss of light reaction indicate brainstem herniation.

2. Monitor the patient’s bilateral motor responses.
Motor dysfunction in TBI often appears contralateral to the site of the injury. It is important to frequently monitor the motor responses of a patient with TBI because any form of deterioration in mobility and abnormal posture can indicate progressive brain injury.

3. Maintain head or neck in midline or neutral position.
Turning the head to one side tends to compress the jugular veins and impedes cerebral venous drainage, which can increase intracranial pressure. To keep the head in a neutral position, use rolled towels or pillows for support as needed.

4. Provide rest periods between care activities and limit the duration of procedures.
Continuous activities and unnecessary stimulation can increase intracranial pressure.

5. Administer IV fluids.
Perfusion can be supported by crystalloid and colloid IV fluids. Hypotonic and dextrose-containing fluids should be avoided. Some instances may require fluid to be restricted.

6. Administer supplemental oxygen as needed.
Providing supplemental oxygen can help reduce hypoxemia. Hypoxemia causes cerebral vasodilation and increased ICP, causing further damage to the brain tissue.

7. Administer medications as indicated.
Diuretics such as mannitol may be prescribed to reduce brain swelling, which helps improve cerebral blood flow and oxygenation.

8. Prepare for surgical intervention as indicated.
Craniotomy may be indicated to help remove bone fragments, elevate depressed fractures, control hemorrhage, evacuate hematoma, and debride necrotic tissues, relieving pressure.


Acute Confusion Care Plan

Patients suffering from mild TBI may experience altered cognition, including acute confusion, decreased memory, and impaired reasoning ability. Additionally, severe TBI can cause prolonged confusion with amnesia.

Nursing Diagnosis: Acute Confusion

Related to:

  • Brain injury
  • Neurologic trauma 
  • Decreased level of consciousness

As evidenced by:

  • Cognitive dysfunction
  • Misperception 
  • Agitation or restlessness

Expected Outcomes:

  • The patient will maintain a baseline level of consciousness and will not experience decreased memory.
  • The patient will be able to respond appropriately to questions.

Acute Confusion Assessment

1. Assess sensory awareness.
Assessment of sensory awareness is crucial to patient safety. Injury to the parietal lobe can cause loss of sensory perception and prevent appropriate responses to environmental stimuli.

2. Assess changes in orientation and personality.
The upper cerebral functions are the first to be affected when there is altered circulation or oxygenation. The damage can occur initially at the onset of the injury or develop later due to swelling or bleeding. Motor, cognitive, perceptual, and personality changes can develop and may persist.

3. Assess the patient’s level of cognitive impairment.
Cognitive impairment can interfere with how the patient with TBI functions. Assessing the patient’s level of cognitive impairment can help determine appropriate rehabilitation.

Acute Confusion Interventions

1. Ensure patient safety.
Patients with acute confusion are not able to follow directions. It is important to promote patient safety by providing a hazard-free environment.

2. Reorient the patient as needed.
Patients with mild TBI may be disoriented and may exhibit short-term memory loss. Frequent reorientation is essential before any interaction to promote a trusting relationship and cooperation from the patient.

3. Keep explanations and activities short and simple.
This allows the patient to better understand the instructions and procedures performed. It is vital to give these explanations before and throughout the patient’s care. They are unlikely to remember long instructions so keep teaching sessions short.

4. Eliminate extraneous noise as necessary.
This can help reduce the patient’s anxiety, confusion, and exaggerated emotional responses associated with sensory overload.

5. Provide structured therapies and activities.
This will help promote consistency and reassurance, reduces the patient’s anxiety and confusion, and promotes a sense of control.


Deficient Knowledge Care Plan 

Many patients suffering from TBI exhibit various long-term physical and cognitive disabilities. Patient and family education is important to clarify misconceptions, implement new behaviors to adapt to the resulting changes, develop coping strategies, and ensure adherence to the plan of care.

Nursing Diagnosis: Deficient Knowledge

Related to:

  • Cognitive dysfunction
  • Inadequate access to resources
  • Inadequate awareness of resources 
  • Inadequate knowledge of resources
  • Misinformation
  • Neurobehavioral manifestations

As evidenced by:

  • Inappropriate behavior
  • Inaccurate statements about topics related to the condition
  • Inaccurate follow-through of instructions 
  • Development of further complications

Expected Outcomes:

  • The patient and/or family will demonstrate knowledge about the condition, treatments, and prognosis as evidenced by verbalization of teaching instructions and adherence with follow-up activities.

Deficient Knowledge Assessment

1. Assess the patient’s cognitive ability.
Patients with TBI may exhibit disorientation, confusion, short-term memory loss, and mood changes. Determine cognition to tailor teaching methods for optimal effectiveness.

2. Assess the patient’s support system.
The patient’s support system is important to identify as those with severe TBI often require at a minimum, assistive care.

Deficient Knowledge Interventions

1. Encourage the patient to participate in developing a relevant treatment regimen.
This will let the patient feel a sense of control in their treatment regimen and likely result in the best outcomes.

2. Encourage the patient and family to participate in required therapies.
Rehabilitation may be indicated for patients after TBI to maximize return to the patient’s highest level of functioning. The patient’s family may be required to provide continuous support to the patient even after the patient is discharged.

3. Discuss possible changes in behavior, mood, and personality at home.
Personality and behavioral problems can develop after TBI. The family must be prepared to cope with the possible changes in the patient’s behavior, personality, and mood.

4. Discuss the importance of follow-up care.
Follow-up care is essential in ensuring the patients return to their highest level of functioning.

5. Instruct the family to develop a structured and consistent home routine.
Patients suffering from TBI respond best to a structured and consistent environment that does not deviate much from their normal routine.


References and Sources

  1. Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, PhD, FAADN, CNE. 2020. Elsevier, Inc.
  2. Lizzo JM, Waseem M, Tatikonda G. Brain Trauma (Nursing) [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568686/
  3. Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
  4. Nakase-Richardson, R., Yablon, S. A., & Sherer, M. (2007). Prospective comparison of acute confusion severity with duration of post-traumatic amnesia in predicting employment outcome after traumatic brain injury. Journal of neurology, neurosurgery, and psychiatry, 78(8), 872–876. https://doi.org/10.1136/jnnp.2006.104190
  5. Shaikh F, Waseem M, Boling AM. Head Trauma (Nursing) [Updated 2021 Nov 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568699/
  6. Traumatic Brain Injury. Cleveland Clinic. © 2022 Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/8874-traumatic-brain-injury
  7. Traumatic Brain Injury. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System. Copyright © 2022. https://www.hopkinsmedicine.org/health/conditions-and-diseases/traumatic-brain-injury
  8. Traumatic Brain Injury & Concussion. Centers for Disease Control and Prevention. March 21, 2022. https://www.cdc.gov/traumaticbraininjury/index.html
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Maegan Wagner, BSN, RN, CCM

Maegan Wagner is registered nurse with over 10 years of healthcare experience. She earned her BSN at Western Governors University. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public.