Xavier University — Ateneo de Cagayan

College of Nursing
A.Y 2021-2022

Concept Map on Cognitive Disorders

In Partial Fulfillment of the Requirements for

NCM 116 - LEC

Submitted by:

Sumandar, Ezra Alexandria

Telow, Jered Brae
Torion, Zenn Pauline
Torre, Carlos Joseton Paulo
Valera, Daniella Kaye
Villanueva, Emiel
Waga, Mikayla
Wong, Jeremiah
Yongco, Sheila Adrianne
BSN 3 - NC (Group 3)

Submitted to:

Mrs. Jesusa C. Gabule

February 18, 2022

 Google Drive Link:

https://drive.google.com/file/d/1iS7b43Qz2GemnHQf_g0iDpMJHDAXb7T_/view?usp
=sharing

Infectious and Inflammatory Concept Map Narrative - Cognitive Disorders

(OR Group - NC3)

I.Systemic Sclerosis
Systemic sclerosis is a rare chronic disease of unknown cause
characterized by diffuse fibrosis and vascular abnormalities in the skin, joints,
and internal organs (especially the abnormalities in the skin, joints, and internal
organs. The illness is triggered by several factors such as viruses,
environmental exposures, autoantibodies, proteolytic enzymes, and
inflammatory cytokines. This vascular insult then leads to endothelial cell
activation followed by the overexpression of adhesion molecules and the
activation of platelets and thrombotic and fibrolytic cascades. This results to
tissue hypoxia which manifests itself in different signs and symptoms such as
the following:
 Raynaud phenomenon
 Insidious swelling of the distal extremities with gradual thickening of the
skin of the fingers
 Polyarthralgia is also prominent
 Heartburn
 Dysphagia
 Dyspnea
This disease is influenced by a number of risk factors. It is predisposed
by one’s family history and immune system and is precipitated by environmental
factors. Systemic Sclerosis can be diagnosed using Antinuclear Antibodies Test
(ANA), Nephelometry test; determining the rheumatoid factor, RNA Polymerase
III test, chest CT scan, echocardiography, and a pulmonary function test. The
disease can complicate into digital infarctions, scarring of lung tissue,
hypertension, myosititis, if not treated properly.

Multiple diagnoses can be made for this disease upon care. First is
Ineffective Tissue Perfusion RT decreased peripheral blood flow. Its
independent interventions include ensuring adequate hydration and
encouraging the patient to stop smoking in order to improve patient outcome.
Its dependent interventions include administering vasodilators and/or
analgesics as prescribed. Next is Impaired physical mobility RT hardening and
tightening of skin. Its independent interventions include assessing patient’s
functional mobility and ability to perform activities of daily living. This is to have
a basis on the client’s changes while under care. It also includes assisting the
patient during exercises, ensuring safety of the environment, and encouraging
the patient to perform range of motion exercises. Its dependent intervention is
focused on referring the patient to physiotherapy and an occupational therapy
team. Lastly, diarrhea related to damage of the digestive tract can be made in
reference to the disease’s ability to disrupt gastrointestinal function. The
independent actions include creating a stool chart to monitor the patient,
 increase oral fluid as tolerated, and helping the patient select appropriate
dietary choices.

I.Spondyloarthropathies
Spondyloarthropathies are defined as a group of diseases characterized
by inflammation in the spine and joints. The exact pathophysiology of SpA
(spondyloarthropathies) is not well understood. What is known is that the
pathogenesis of each of the other members of the SpA, is probably closely
related to that of ankylosing spondylosis. The pathophysiology of these
conditions generally start because of three factors which are the presence of
HLA B27 on wbc, genes encoding Tumor Necrosis Factors, or possible
exposure to enteric bacteria. This leads to a high number of CD4+ and CD8+ T
cells and macrophages being activated by misfolded B27 protein and the
activation of the immune system as a result. The final result is inflammation in
the joints and other connective tissues. The predisposing factors for this
condition are, family history, male gender, psoriasis, and IBD. While the
precipitating factor is bacterial infections like salmonella or a sexually
transmitted bacteria.

Complications for spondyloarthropathies include eye inflammation,

osteoporosis leading to increased risk of fracture or spinal cord injury, the spine
may fuse leading to limited flexibility and increased risk of spine fracture/spinal
cord injury, fusion in the rib cage leading to limited lung capacity and
function.Spondyloarthropathies may manifest in the following ways, Long
standing low back pain, back stiffness, back pain and stiffness that is worse at
night and improves with exercise, fatigue, painful swelling of joints, sausage-
like appearance of fingers or toes, heel pain, skin and nail changes (associated
with psoriatic arthritis), and uveitis. Diagnostic tests for this condition include x-
rays which shows spine and joint changes indicative of PsA or AS, MRIs which
shows active inflammation in the spine or joints, blood tests that helps rule out
other inflammatory conditions like rheumatoid arthritis, and tests for HLA-B27
gene which is useful in diagnosis, and joint fluid test to rule out gout.

Now moving onto the nursing diagnoses and nursing management for
spondyloarthropathies. The first nursing diagnosis we have is chronic pain r/t
vertebral and joint inflammation secondary to disease process. The
independent interventions include assessing v.s. and asking patient to rate and
describe their pain, asking patient to re-rate their pain 30 mins to an hour after
taking pain meds, implementing non pharmacological interventions when pain
is well controlled by pain meds, and repositioning the patient in a comfortable
position. The dependent interventions include administering medication like
NSAIDs, DMARDs, and Biologics as prescribed by the doctor and physical
therapy. For the second nursing diagnosis we have activity intolerance r/t
vertebral and joint inflammation, pain, and back and neck stiffness secondary
to disease process. The independent interventions are to assess ability to
perform ADLs as well as actual and perceived limitations to physical activity,
encourage progressive activity through self-care and exercise as tolerated and
explain the need to reduce sedentary activities, and alternate periods of
physical activity with 60-90 minutes of undisturbed rest. The dependent
 interventions are to refer the patient to physiotherapy and administer NSAIDs,
Biologics, and DMARDs as prescribed by the doctor.

The last nursing diagnosis is impaired physical mobility r/t vertebral and
joint inflammation and fusion of the spine secondary to disease process. The
independent interventions are to assess ability to perform ADLs, identify
patient’s need for assistance and educate significant others on how to assist
the patient in performing ADLs, and encourage physical mobility and
demonstrate ROM. For the dependent interventions, they include referring to
physiotherapists and assisting in hip replacement surgery if needed.

I.Fibromyalgia Syndrome
Fibromyalgia is referred to as “widespread pain” all over the body, sleep
problems, fatigue, and often emotional and mental distress. There’s no known
cause of fibromyalgia syndrome and it’s neither life-threatening nor progressive.
Aberrant pain processing results in chronic pain and other factors may play a
role in the mechanisms. Central sensitization, blunting of inhibitory pain
pathways and alterations in neurotransmitters lead to aberrant neuro-chemical
processing of sensory signals in the central nervous system which in turn will
lower the threshold of pain and will amplify the normal sensory signals causing
constant pain. Clinical manifestations of FMS are Pain and stiffness all over the
body fatigue and tiredness, depression and anxiety, sleep problems, problems
with thinking, memory, and concentration, headaches, including migraines,
tingling or numbness in hands and feet, pain in the face or jaw, including
disorders of the jaw known as temporomandibular joint syndrome (also known
as TMJ), digestive problems, such as abdominal pain, bloating, constipation,
and even irritable bowel syndrome (also known as IBS). The predisposing
factors involved in this case are age, sex, obesity, and family history while the
precipitating factors include having lupus or rheumatoid arthritis, when you’ve
experienced stressful or traumatic events like car accidents, PTSD, repetitive
injuries, and illnesses like viral infections. Fibromyalgia syndrome might lead to
more hospitalizations, lower quality of life, higher rates of major depression,
higher death rates from suicide and injuries, or higher rates of other rheumatic
conditions. Diagnostic tests involve blood work which are: Complete blood
count, Erythrocyte sedimentation rate, Cyclic citrullinated peptide test,
Rheumatoid factor, Thyroid function tests, Antinuclear antibody, Celiac
serology, Vitamin D, and X-rays.

The first nursing diagnosis is Chronic pain secondary to disease

condition as evidenced by pain scale of 8 out of 10, guarding on the affected
side, and facial grimacing. Nursing interventions include: Encourage deep
breathing. Apply cold compress. Advise the patient to use guided imagery or
distraction. Encourage the patient to assume a position of comfort. The
dependent action would be to administer analgesic as ordered.
The second nursing diagnosis is Disturbance of sleep pattern related to
wakefulness secondary to disease condition as evidenced by fatigue and lack
of energy. Independent nursing actions would be to: Encourage the patient to
adhere to a dedicated and consistent sleep and rest schedule. Advise the
patient to drink a glass of milk before sleeping. Educate the patient on several
measures to promote sleep like avoiding heavy meals before sleeping, smoking
 before bedtime, drinking caffeine-containing beverages and alcohol. Promote a
sleep conducive environment. The dependent action is to administer a sedative
as ordered by the physician.

The last nursing diagnosis is Impaired physical mobility R/T discomfort

and pain. The independent nursing actions would be to: Monitor and continue
monitoring the degree of inflammation or pain. Maintain bed or chair rest if
indicated. Schedule activities of frequent rest periods and uninterrupted night
time sleep. Assist the patient with active or passive ROM. Encourage
the patient to maintain upright and erect posture when sitting, standing, and
walking. Reposition the patient frequently. Discuss and provide safety needs.
The dependent nursing action is to consult with a physician or occupational
therapist.

I.Seizures (Epilepsy)
The disease epilepsy is defined to be a central system disorder in which brain
activity becomes abnormal. This disorder causes seizures or periods of unusual
behavior, sensations, and sometimes, loss of awareness. The seizures that come
along with this disorder are generally divided into two which then branches out to more
subtypes of seizures. The two types of main seizures are partial-onset seizures and
generalized-onset seizures. Despite resulting into similar signs of seizures, the
pathophysiology of these two types are slightly different. For the partial-onset seizures,
they occur due to a lesion or defect in the area of the cerebral cortex that controls
voluntary movement or in the temporal or frontal lobe that controls memory or
executive function. The said lesion or defect then causes disruption of function in the
specific area of the brain that it is located in. With that, there is an onset of seizure
which then affects a person in a way that is not that serious. When a person
experiences a partial-onset seizure, he or she may be fully aware and may also not
lose consciousness but may experience muscle jerking or stiffening. The other type of
seizure associated with epilepsy are generalized-onset seizures. During this type of
seizure, tests show abnormal electrical activity in most, if not all, parts of the brain.
This then leads to generalized muscle jerking. Because of the strain asserted on the
muscles affected by the said type of seizure, there may be a loss of muscle tone.

The first factor that predisposes a person to the said disease is age due to it’s
more occurence and diagnosis in children and people over the age of 65. Presence of
epilepsy in other members of a person’s family may also put a person at risk of
epilepsy. Due to their effect on the electrical activity of a person, certain diseases like
stroke, dementia, and other brain infections may also increase the chances of a person
getting the neuromuscular disorder. Factors that directly influence the presence of the
said disorder in the person may include genetics, head trauma, brain abnormalities,
general infections, prenatal injuries, and other developmental disorders.
Complications that may arise when a person suffers with epilepsy may include
permanent brain damage, status epilepticus, which is discussed in the following
disorder narrative, complications with one’s pregnancy, and in worst cases, death.
Signs and symptoms that may be seen or associated with epilepsy include temporary
confusion, muscle stiffness, uncontrollable jerking movements of the arms and legs,
loss of consciousness or awareness, fear, and anxiety. Tests that may be conducted
to diagnose the said disorder are composed of complete physical examinations,
 prolactin studies, and neurological examinations. Imaging studies to diagnose the
disease include the use of electroencephalogram (EEG), magnetic resonance imaging
(MRI), positron emission tomography (PET), single photon emission computed
tomography (SPECT), and magnetic resonance spectroscopy (MRS).

The first nursing diagnosis for this disease is the risk for injury related to loss of
sensory coordination and muscular control secondary to seizures. Independent
nursing interventions include the exploration of the usual seizure pattern of the patient,
the placement of the bed of the patient in the lowest position along with putting pads
on the rails of the bed and on the floor to reduce the risk of injury during the occurrence
of a seizure. The dependent nursing intervention associated with the nursing diagnosis
given would be the administration of medications such as benzodiazepines,
anticonvulsants, antiepileptics, and other seizure drugs as prescribed by the physician.
The second nursing diagnosis is deficient knowledge related to seizures. The
independent nursing interventions associated with this nursing diagnosis would be to
assess the patient’s readiness to learn, known misconceptions, and blocks to learning,
explain what seizures are, its types, and related signs and symptoms in laymans
terms, educate the patient about safety measures related to epilepsy and seizure
activity, and to inform the patient about the details about the medications prescribed
to him or her by the doctor.

The last nursing diagnosis associated with epilepsy would be the risk for
ineffective airway clearance. The independent nursing interventions associated with
the said nursing diagnosis is the monitoring of the patient’s respiratory rate, rhythm,
depth, and effort of respiration, the assessment of the client’s ability to cough, the
maintenance of the lying position of the client, and the ensuring of the emptying of the
patient’s mouth of dentures or foreign objects during the possibility of a seizure attack.

I.Seizure (Status Epilepticus)

Status epilepticus (acute prolonged seizure activity) is a series of generalized
seizures that occur without full recovery of consciousness between attacks. The
condition is a medical emergency that is characterized by continuous clinical or
electrical seizures lasting at least 30 minutes. The predisposing factors includes:
poorly controlled epilepsy, low blood sugar, stroke, kidney failure, liver failure,
encephalitis (swelling or inflammation of the brain), HIV, alcohol or drug abuse, genetic
diseases such as fragile x syndrome and angelman syndrome and head injuries. The
Precipitating Factors are: withdrawal of anti seizure medication, fever, concurrent
infection, stroke, and imbalance of substances in the blood, such as low blood sugar.
The disease pathology of status epilepticus is when there is an electrical disturbance
(dysrhythmia) in the nerve cells in one section of the brain; these cells then emit
abnormal, recurring, uncontrolled electrical discharges. Wherein there is an excessive
neuronal discharge is a manifestation of a seizure (status epilepticus). Disease
Complications of this disease are stroke or brain injury, physical disability, or even
worse death. The possible signs and symptoms of this disease include muscle
spasms, falling, confusion, unusual noises, loss of bowel or bladder control, clenched
teeth, irregular breathing, unusual behavior, difficulty speaking and a "daydreaming"
look. So how is epilepticus diagnosed? The healthcare provider will do a thorough
physical exam and ask about health history, any medicines you are taking, and if
you’ve been using alcohol or other recreational drugs. An electroencephalogram may
 also be ordered as this involves placing painless electrodes onto your scalp to
measure the brain's electrical activity. Other tests may also be needed to search for
possible causes. These include a lumbar puncture (spinal tap) to look for signs of
infection. A CT scan or MRI may be needed to see problems in the brain. There are
(2) nursing diagnosis for status epilepticus which are Risk for injury related to seizure
activity and Fear related to possibility of having seizures.

The first nursing diagnosis is risk for injury related to seizure activity. The
independent nursing interventions includes: Performing periodic physical
examinations and laboratory tests for patients taking medications known to have toxic
hematopoietic, genitourinary, or hepatic effects. Provide ongoing assessment and
monitoring of respiratory and cardiac function. Monitor the seizure type and general
condition of the patient. Turn the patient to a side-lying position to assist in draining
pharyngeal secretions. Have suction equipment available if the patient aspirates.
Monitor IV line closely for dislodgement during seizures. Protect patients from injury
during seizures with padded side rails and keep under constant observation. Do not
restrain the patient's movements during seizure activity. For dependent nursing
intervention is to Administer anti-epileptic drugs as prescribed by the physician.

The second nursing diagnosis is Fear related to the possibility of having

seizures. The independent nursing intervention includes: Reduce fear that a seizure
may occur unexpectedly by encouraging compliance with prescribed treatment.
Emphasize to the patient that the prescribed antiepileptic medication must be taken
on a continuing basis and is not habit forming. Assess lifestyle and environment to
determine factors that precipitate seizures, such as emotional disturbances,
environmental stressors, onset of menstruation, or fever. And encourage patient to
avoid such stimuli. Encourage patient to follow a regular and moderate routine in
lifestyle, diet (avoiding excessive stimulants), exercise, and rest (regular sleep
patterns). Advise patient to avoid photic stimulation (eg, bright flickering lights,
television viewing); dark glasses or covering one eye may help. Encourage patient to
attend classes on stress management. The dependent nursing intervention is to
administer sedatives as per doctor's order.

The third nursing diagnosis is Ineffective coping related to stresses imposed by

epilepsy. The independent nursing interventions are: To let the patient understand that
epilepsy imposes feelings of stigmatization, alienation, depression, and uncertainty,
Provide counseling to patient and family to help them understand the condition and
limitations imposed. Encourage patient to participate in social and recreational
activities. Teach patient and family about symptoms and their management.And for
the dependent nursing interventions is to administer sedatives as per doctor's order.

I.Head Injuries

Head Injuries can include fractures to the skull and face, direct injuries to the
brain (as from a bullet), and indirect injuries to the brain (such as a concussion,
contusion, or intracranial hemorrhage). Head injuries commonly occur from motor
vehicle accidents, assaults, or falls. Accidents and/or intense physical activity which
affects the head that then leads to trauma to the skull more than the skull can handle
is what causes head injuries
 Factors that predispose a person to sustaining head injuries include being male
who are twice as likely than females to sustain a traumatic brain injury. African
Americans also have high mortality rates. People in the age group 15-19 are at the
highest risk meanwhile adults 75 years of age and older have the highest TBI related
hospitalization and death rate. Precipitating factors include getting involved in falls,
motor vehicle crashes, being struck by objects, and assault.

Many people who have had a significant head injury will experience a minimally
conscious state which is a condition of severely altered consciousness but with some
signs of self-awareness or awareness of one's environment. A comatose may also
happen as this results from widespread damage to all parts of the brain. After a few
days to a few weeks, a person may emerge from a coma or enter a vegetative state.
In worse case scenarios, it will escalate to traumatic brain injury (TBI) and even death.

Signs and symptoms that a patient may be experiencing a head injury is

persistent localized pain that usually suggests a fracture is present. Hemorrhage from
the nose, pharynx, or ears may be due to fracture in the base of the skull which
traverses to the paranasal sinus of the frontal bone or the middle ear. An ecchymosis
(or bruising) over the mastoid cerebrospinal fluid leak in the ears and nose suggests
that a basilar skull fracture is present.

To diagnose head injuries an evaluation of neurologic status is done to detect

obvious brain injuries. A physical examination, inspection, and palpation is important
to diagnose a scalp injury. An x-ray confirms the presence and extent of skull fracture
and swelling. A computed tomography (CT) scan shows the presence, nature,
location, and extent of acute lesions. Magnetic resonance imaging (MRI) is used to
evaluate patients with head injury. Cerebral angiography is used to identify
suprainterioral, extracerebral, and intracerebral hematomas and cerebral contusions.
Prioritized nursing diagnosis include Decreased intracranial adaptive capacity
related to increased intracranial pressure. For this, the nurse must monitor the
patient’s neurological status meaning the level of consciousness, pupils, Glasgow
Coma scale scores and vital signs regularly. It is also important to assess for fluid
leakage from ears and nose which might be cerebrospinal fluid caused by fractures in
the skull. Besides administering medications as ordered, nurses must also teach the
client to avoid any activities and symptoms that increase ICP (intracranial pressure)
like position changes, endotracheal tubing, coughing, vomiting among others.
Another Nursing diagnosis for head injury patients is Acute confusion related to
increased intracranial pressure. For this, the nurse must assess the patient’s level of
consciousness at a regular interval because a change in mental status might indicate
an increase in cerebral pressures. Since the patient is possibly confused, we must
reorient the patient to person, time, place, and situation frequently. Introducing
ourselves before any interaction and intervention also helps in the condition of the
patient.
Lastly, the prioritized nursing diagnosis for these kinds of patients includes
deficient knowledge related to lack of experience with head injury. Just like the
previous interventions, we must assess the patient’s cognitive ability and
receptiveness to learning information because some patients might be disoriented. We
must also update the patient and family members regularly about changes in health
 status and assess the patient’s knowledge about injury to possibly formulate treatment
plans.

I.Brain Injuries
Brain injury or damage occurs when blood flow is obstructed and tissue
perfusion is decreased. Traumatic brain injury, closed (blunt) is when the head
accelerates and rapidly decelerates or collides with another object. Brain tissue then
is damaged but there is no opening through the skull and dura. Traumatic brain injury,
open (penetrating) is when an object penetrates the skull and enters the brain which
damages the soft brain tissue along its path. But a blunt trauma may be considered
open if the damage is so severe that it opens the scalp, skull, and dura to expose the
brain.

Contusion is when the brain is bruised and damaged at a specific area because
of severe acceleration-deceleration force or blunt trauma. The brain would impact the
skull and this leads to a contusion. The predisposing factors for this condition are
young age of 0-4 years old, advanced age of 60 years old and more, the male gender,
and dangerous or accident-prone environments like a construction site or armed
conflicts. The precipitating factors are accidents due to falls, moving objects, or
vehicular accidents, intended harm or violence like assault, and sport injuries like
boxing. Complications for this disease are coma, brain death, seizures, infection,
hydrocephalus, and tentorial herniation. The main sign and symptom is loss of
consciousness with stupor and confusion. Other signs and symptoms may include
changes in cognition, speech difficulty, inability to concentrate, increase in ICP, and
numbness and tingling. The diagnostic tests are CT scan to visualize and uncover
fractures, tissue swelling, bruised brain tissue, hemorrhages, and hematomas, MRI for
a more detailed image of the brain, and intracranial pressure monitor.

As brain injuries may result in breathing problems, the first nursing diagnosis
priority is ineffective breathing pattern related to brain injury. The independent
interventions are to elevate the head of the bed in 30 degrees to decrease intracranial
pressure, suction patient’s airway to clear secretions as needed, and closely monitor
vital signs for decreased oxygenation. The dependent intervention is to administer
oxygen or assist in patient intubation per doctor’s order. The second nursing diagnosis
acute confusion related to brain injury and for this the nurse may assess level of
consciousness, reorient patient to patient, time, place, and situation as needed, and
provide a calm environment for the patient. While the dependent intervention is to
administer medications to treat the underlying condition as ordered or consult with a
physician. The third nursing diagnosis is ineffective coping related to brain injury for
the patient may be stressed on the possibility of their brain being damaged. The
nursing independent interventions here are to use therapeutic communication, provide
methods to express fears and emotions, and provide information as patient needs.
The dependent intervention is to refer for counseling or social services if needed.

Hematomas are collections of blood in the brain and may be epidural (above
the dura), subdural (below the dura), or intracerebral (within the brain). Major
symptoms are mostly delayed until hematoma is big enough to cause brain distortion
and increased ICP. When a strong force impacts the head or body, the brain hits
against the skull and the skull may be fractured and lacerated which in turn could
rupture a blood vessel. Blood then begins to collect in the nearby space. The
predisposing factors are advanced age of 60 years old and more, gender being male,
certain medications like anticoagulant and blood thinners, alcohol intake, drug abuse,
smoking, and hypertension. The precipitating factors are accidents due to falls, moving
objects, or vehicular accidents, intended harm or violence like assault, and sport
injuries like boxing. The signs and symptoms include Increasing headache, vomiting,
drowsiness and progressive loss of consciousness, dizziness, confusion, unequal
pupil size, slurred speech, loss of movement (paralysis) on the opposite side of the
body from the head injury. The diagnostic tests are CT scan to visualize and uncover
fractures, tissue swelling, bruised brain tissue, hemorrhages, and hematomas, MRI for
a more detailed image of the brain, and intracranial pressure monitor. Therapeutic
interventions include surgical evaluation for evacuation of clot and reversal of
coagulopathies and iatrogenic anticoagulation. Also multiple burr holes or craniotomy
is performed when the blood mass cannot be drained or suctioned by a burr hole.

As brain injuries may result in breathing problems, the first nursing diagnosis
priority is ineffective breathing pattern related to brain injury. The independent
interventions are to elevate the head of the bed in 30 degrees to decrease intracranial
pressure, suction patient’s airway to clear secretions as needed, and closely monitor
vital signs for decreased oxygenation. The next concern is the patient being
dehydrated or abnormal fluid shift and this leads to the second nursing diagnosis of
deficient fluid volume related to decreased LOC and hormonal dysfunction. The
independent interventions are record weight and I&O daily to monitor for fluid shift,
dress clients in light clothing to reduce heat and fluid loss, and perform oral hygiene
to avoid dry mouth. The dependent intervention is to administer parenteral fluids per
doctor’s order. The third nursing diagnosis is disturbed sensory perception related to
brain injury and the nurse should keep sensory stimulation to a minimum, advise the
client to not drive at night and have sufficient lighting at home, and educate client and
SO on safety measures to prevent injuries. The dependent intervention is to administer
medications as ordered by the physician.

Diffuse axonal injury is a type of traumatic brain injury resulting from blunt
trauma to the brain involving the long connective nerve fibers. DAI occurs when there
is an acceleration-deceleration and rotatory shearing forces. The brain then rapidly
shifts inside the skull. Damaged nerve axons, often extending to the white matter. DAI
is often hard to detect; common diagnostic tests performed are an MRI and a CT scan
to detect small punctate hemorrhages to white matter tracts.

Shaken baby syndrome and child abuse may predispose to diffuse axonal
injury. Its precipitating factors may then include high-energy trauma (e.g., traffic
accidents), sports accidents, assault, and falls. DAI can present in a wide range of
neurological dysfunction from a mere headache to being in a vegetative state. Some
manifestations include disorientation or confusion, nausea and vomiting, drowsiness
or fatigue, trouble sleeping or sleeping longer than normal, loss of balance or
dizziness, loss of consciousness, and dysautonomia (i.e., tachycardia, tachypnea,
diaphoresis, vasoplegia, hyperthermia, abnormal muscle tone, and posturing).

Disease complications of a diffuse axonal injury include a prolonged traumatic

coma. Edema that develops due to the injury often increases the ICP that could lead
to cerebral ischemia or anoxia and death.
 Clients with DAI often have altering losses of consciousness, often caused by
neurological examinations. The nursing diagnosis would then be disturbed sleep
pattern related to brain injury. Intervention mainly revolves around supportive care,
such as providing a quiet and calm environment with the room lights dimmed as well
as other necessary comfort measures.

Another nursing diagnosis would be a risk for ineffective cerebral perfusion

related to increased ICP. Independent nursing interventions include elevating the head
of the bed at 30-45 degrees, controlling environmental temperature, providing rest
periods between care activities and preventing duration of procedures, and
reorientation to the environment as needed. Administration of anticonvulsants may be
provided, as ordered.

There is also a risk for imbalanced nutrition: less than body requirements
related to impaired level of consciousness. As such, maintain the head of the bed at
30 degrees and avoid inserting a feeding tube through the nose in case of basilar
fractures. Tube feedings are administered as ordered.