Head Trauma and Nursing Intervention

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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.

Concussion
-    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.

Contusion
-    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.

Lacerations
-    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

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

Intracerebral
-    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.

Causes
-    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.

Hyperventilation
-    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

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