ACUTE AND INTERMEDIATE PHASE NURSING IN TBI: GASTROINTESTINAL, NUTRITION, AND BLADDER COMPLICATIONS

  1. Problems include:
    • GI hemorrhage, paralytic ileus, Cushing's ulcer in the upper GI tract, stress ulcers in duodenum, absent gag reflex, constipation, and incontinence
    • Diabetes insipidus, syndrome of inappropriate secretion of ADH (SIADH), electrolyte imbalance, hyperosmolar nonketotic hyperglycemia, hyponatremia, and hypokalcemia
    • Alteration in the amount of urinary output and urinary incontinence

  2. Causes include:
    • Injury to the GI tract, bed rest, fluid restriction, adverse effects of analgesics, and coma
    • Inadequate nutrition and fluid intake for stress response following TBI

  3. Nursing Diagnoses include:
    • Gastric ulceration and bleeding, constipation, and bowel incontinence
    • Impaired swallowing and risk for aspiration
    • Fluid volume deficit and inadequate nutrition for body requirements
    • Altered urinary elimination and urinary incontinence

  4. Assessments include:
    • Bowel sounds and bowel distention, and hemoglobin studies
    • Fluid and electrolyte balance, recording of weight if possible, hematocrit, electrolyte studies, glucose level, acetone level, and osmolality
    • Swallowing reflex assessment
    • I&O record

  5. Nursing Interventions include:
    • Monitoring stools for occult blood, monitoring pH of gastric contents by NG tube aspiration every 4-6 hours, auscultation of the abdomen once per shift, observing for changes in vital signs, and establishing a bowel program
    • Ensuring that a nutrition consultation occur and appropriate feeding is begun as soon as possible, and supervising the patient during meal and snack time
    • Monitoring I&O record for excessive output, monitoring fractional urinary output every 1-2 hours, monitoring central venous pressure readings, checking urine-specific gravity every 1-4 hours, monitoring body weight 2X/week, and treating any metabolic/nutritional problems, e.g.
      • Higher concentration of IV saline solution, extra salt to tube feeding, and drug therapy, such as fludrocortisone acetate to treat hyponatremia
      • Replacement with potassium chloride to treat hypokalcemia
      • Glucose management with diet changes or insulin to treat hyperglycemia which may aggravate the ischemic insult following TBI
      • Fluid replacement to achieve euvolemia and prevent hypotension and secondary brain injury
    • Maintaining an indwelling urinary catheter or condom catheter and monitoring the 24-hour I&O for signs of fluid retention or dehydration

Based on information in Hickey JV. The Clinical Practice of Neurological and Neurosurgical Nursing, 4th ed., Philadelphia: Lippincott, 1997 and in Chin PA, et al. Rehabilitation Nursing Practice, N.Y.: McGraw-Hill, 1998, except for information where other papers are cited.