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Case Study: An 85 year old female patient was brought to the ER after a fall in her bathroom, striking her head on the pedestal sink. She arrived in the ER on a non-rebreather via Emergency Medical Services. She has a known history of diabetes, chronic kidney disease, hypertension, hypothyroidism and congestive heart failure. Her Glasgow Coma Scale measured 13 with no focal neurological deficits. Upon initial exam you find that the patient has an occipital  laceration, but no signs of skull fracture.

A. Develop a three-diagnosis care plan for the patient with a Traumatic Brain Injury 

B.  One nursing diagnosis should be a priority nursing diagnosis, and one should be related to discharge planning.  Each nursing diagnosis should be a 3-part nursing diagnosis (ex. Nanda Nursing diagnosis ——–related to ——–as manifested by…).          

C. The Priority and Discharge nursing diagnosis should include:

    1. A specific and measurable goal statement

    2. Three (3) Nursing Interventions

    3. A measurable Evaluation statement for the goal.

SCIENCE
HEALTH SCIENCE
NURSING

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