ACUTE AND INTERMEDIATE PHASE NURSING IN TBI: SKIN AND MUSCULOSKELETAL MOBILITY

  1. Problems include immobility, skin breakdown, and decerebrate or decorticate posturing

  2. Causes include the injury, immobility, and intubation

  3. Nursing Diagnoses include risk for impaired skin integrity, altered peripheral tissue perfusion, altered oral mucous membrane, impaired physical mobility (limited physical movement in the environment), and risk for disuse syndrome

  4. Assessments include integrity and character of the skin, ROM of joints, and development of deformities or spasticity

  5. Nursing Interventions include:
    • Skin Care:
      • Provide skin care every 4 hours
      • Turn the patient every 2-4 hours
      • Provide mouth care every 2-4 hours
      • Monitor for signs and symptoms of skin breakdown
      • Institute precautions and skin treatment as needed
    • Mobility:
      • Monitor joint ROM and provide ROM exercises every 4 hours
      • Properly position the patient, which may be complicated by nuchal rigidity, spasticity, casts, and lacerations or contusions
        • Unconscious patient should be repositioned every 1 - 2 hours
          • never place an unconscious patient in the supine position because of possible aspiration or airway occlusion
          • side-lying position, with head of the bed elevated and head in a neutral position, can facilitate drainage
          • modified position, halfway between supine and side-lying, can relieve pressure in patients needing long-term bed rest
        • Frequent repositioning is necessary if spasticity or rigidity is present
      • Assist with splints
      • Control noxious stimuli

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.