Head Trauma and Nursing Intervention

Head Trauma
-    Majority of head injury deaths occur immediately from direct trauma or from massive hemorrhage and shock.
-    Acute head injury results from a trauma to the head, leading to brain injury or bleeding within the brain. Effects of injury may include edema and hypoxia.
-    A head injury is classified by brain injury types: fracture, hemorrhage, or trauma.
-    Hemorrhages are classified as epidural, subdural, intracerebral, or subarachnoid.
-    Deaths occurring in a few hours are caused by progressive worsening of head injury or from internal bleeding.
-    Usually signifies craniocerebral trauma
-    Includes alteration in consciousness
-    High potential for poor outcome
-    Death at injury
-    Death within 2 hours after injury
-    Death 3 weeks after injury
-    Scalp lacerations – scalp has many blood vessels and will bleed profusely.
-    Skull fracture types

-    Linear
-    Depressed
-    Simple
-    Comminuted

Skull Fracture Locations
-    Frontal
-    Orbital fracture
-    Temporal fracture
-    Parietal fracture
-    Posterior fossa fracture
-    Basilar skull fracture
-    Occurs at base of the skull
-    Watch for rhinorrhea and otorrhea (leakage CSF)
-    Test fluid leaking from nose or ear for glucose.
Classification of head injury
•    Primary brain injury:
Is the direct injury that occurs to the brain, include: concussion, contusion, hematoma
•    Secondary brain injury:
Complicates the situation following a primary brain injury and is the result of hypoxia, hypotension, anemia, hypercarbia or infection.

-    This injury results in the temporary failure of impulse conduction. The neurological deficit are reversible and generally mild.
-    Patient may lose consciousness for a few seconds at the time of injury, but lasting effect are not common.
-    Altered level of consciousness, confusion and disoriented.

-    Is the result of injuries accompanied by bruising and generalized hemorrhage into brain tissue.
-    Injury can be to the areas are prone to bleeding and swelling, they act as an intracranial expanding mass.

-    Tearing of brain tissue
-    Occurs with depressed skull fracture and penetrating injuries
-    May have bleeding into the brain structures-intracerebral hemorrhage
-    Very difficult to remove blood
Epidural hematoma
-    Comes from bleeding between dura and inner surface of the skull
-    Tearing of an artery from a skull fracture, brisk bleeding and rapid accumulation in the epidural space
-    Will be unconscious, then awake, and then deteriorate
-    Headache, nausea and vomiting
-    Needs surgical intervention to prevent brain herniation and death

Subdural Hematoma
-    Usually bleeding is from veins, so bleeding is generally slower than epidurals
-    CAN be from arteries and these require IMMEDIATE removal
-    Bleeding in the subarachnoid space from the rupture of a traumatic aneurysm; altered LOC, headache and photophobia.

Diagnostic Studies
-    Skull x-rays routine to r/o or identify fracture
-    CT/MRI are best to determine trauma rapidly

-    Bleeding to the ventricles; altered of LOC, cranial nerve dysfunction, motor changes.

-    Bleeding into brain tissue, producing necrosis.
-    Is a large hemorrhage into brain tissue that creates a mass lesion. This lesion can occur anywhere in the brain.

-    Assault
-    Automobile accident
-    Blunt trauma
-    Fall
-    Penetrating trauma

Assessment finding
-    Decrease level of consciousness LOC
-    Disorientation to time, place, or person
-    Otorrhea, rhinorrhea (if CSF leak occurs).
-    Unequal pupil size, loss of pupillary reaction.
Diagnostic Test Results
-    CT scan shows hemorrhage, cerebral edema, or shift or midline structures.
-    EEG may reveal seizure activity.
-    ICP monitoring shows increase ICP.
-    MRI shows hemorrhage, cerebral edema, or shift or midline structure.
-    Skull x-ray may show skull fracture.
Emergency Management-Initial
-    Airway
-    Stabilize cervical spine
-    Oxygen administration
-    IV access (2 large bore catheters), LR or NS
-    Control external bleeding with pressure
-    Assess for rhinorrhea, otorrhea, scalp wounds
-    Remove clothing

Emergency Management-Ongoing
-    Maintain patient warmth
-    Monitor VS, LOC, O2 sats, cardiac rhythm, GCS, pupil size and reactivity
-    Anticipate intubation if absent gag reflex
-    Assume neck injury with head injury
-    Administer fluids cautiously to prevent IICP

Medical (Nonsurgical) intervention
-    The treatment of a patient with a head injury is the same as for a patient with increase ICP.
-    The emphasis is on reducing ICP, maintaining the airway, provide oxygenation, maintaining cerebral perfusion and prevent secondary head injury.

-    Acute hyperventilation decrease PaCo2, causing vasoconstriction of the cerebral arteries, reducing cerebral blood flow, decrease intracranial pressure.
-    Using hyperventilation over a long period  of time is contraindication and may not reduce ICP significantly.
-    Physicians may utilize the technique by setting the ventilator at a rate that produces hyperventilation.
-    PaCo2 is generally maintained at (30-35 mmHg)

Surgical Interventions
-    A variety of surgical procedures exist for head injury patient.
-    For a patient with depressed skull fracture, elevation of the fracture may be needed, depending on the nature of the fracture.
-    Surgical removal of an epidural, subdural or intracerebral hematoma may be perfomred to prevent a mass lesion from causing a shift in brain tissue or herniation.
Types of Cranial Surgery: Craniotomy
-    Penetrating wounds to the skull and brain may necessitate a craniotomy, remove bone fragments and repair laceration
-    Location varies
-    Frontal, Parietal, Occipital, Temporal or
-    Combination
-    Burr holes drilled, saw to remove bone flap
-    Bone flap wired or sutured after surgery
-    Drain may be placed to remove blood or fluid

Nursing Care: Pre-op
-    Teaching
-    What can be expected
-    Hair will be shaved
-    Client will be in ICU after surgery
Nursing Care: Post-op
-    Prevent increased ICP.
-    Maximum swelling occurs within 24-48 hours
-    Frequent assessment of neuro status x 48 hrs.
-    Monitor fluids, electrolytes, osmolality closely
-    Detects changes in sodium regulation, onset of diabetes insipidus, severe hypovolemia
-    Positioning varies depending on procedure
-    Assess dressing, drainage, incision
-    Care to prevent wound infection

Nursing Care: ambulatory and home
-    Rehab potential depends on reason for surgery, post-op course of recovery, and client’s

Related posts:

Posted in Neurology, Nursing Care Plans, Nursing Intervention

FaceBook Page