A head injury is any trauma that leads to injury of the scalp, skull, or brain.

The injuries can range from a minor bump on the skull to serious brain injury. Head injury is classified as either closed or open (penetrating).

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Fluid draining from nose, mouth, or ears (may be clear or bloody) Fracture in the skull or face, bruising of the face, swelling at the site of the injury, or scalp wound Irritability (especially in children) Loss of consciousness, confusion, or drowsiness Loss of or change in sensation, hearing, vision, taste, or smell Low breathing rate or drop in blood pressure Memory loss Mood, personality, or behavioral changes Paralysis Restlessness, clumsiness, or lack of coordination Seizures Speech and language problems Slurred speech or blurred vision Stiff neck or vomiting Symptoms improve, and then suddenly get worse (change in consciousness)

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A closed head injury means you received a hard blow to the head from striking an object, but the object did not break the skull. An open, or penetrating, head injury means you were hit with an object that broke the skull and entered the brain. This usually happens when you move at high speed, such as going through the windshield during a car accident. It can also happen from a gunshot to the head.

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through the cloth, do NOT remove it. Place another cloth over the first one. If you suspect a skull fracture, do NOT apply direct pressure to the bleeding site, and do NOT remove any debris from the wound. Cover the wound with sterile gauze dressing. If the person is vomiting, roll the head, neck, and body as one unit to prevent choking. This still protects the spine, which you must always assume is injured in the case of a head injury. (Children often vomit once after a head injury. This may not be a problem, but call a doctor for further guidance.) Apply ice packs to swollen areas.

Head injuries include:

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Causes

Concussion, the most common type of traumatic brain injury, in which the brain is shaken Contusion, which is a bruise on the brain Scalp wounds Skull fractures

For a mild head injury, no specific treatment may be needed. However, closely watch the person for any concerning symptoms over the next 24 hours. The symptoms of a serious head injury can be delayed. While the person is sleeping, wake him or her every 2 to 3 hours and ask simple questions to check alertness, such as "What is your name?" If a child begins to play or run immediately after getting a bump on the head, serious injury is unlikely. However, as with anyone with a head injury, closely watch the child for 24 hours after the incident. Over-the-counter pain medicine, such as acetaminophen, may be used for a mild headache. Do NOT take aspirin, ibuprofen, or other anti-inflammatory medications because they can increase the risk of bleeding. DO NOT Do NOT wash a head wound that is deep or bleeding a lot. Do NOT remove any object sticking out of a wound. Do NOT move the person unless absolutely necessary. Do NOT shake the person if he or she seems dazed. Do NOT remove a helmet if you suspect a serious head injury. Do NOT pick up a fallen child with any sign of head injury. Do NOT drink alcohol within 48 hours of a serious head injury.

First Aid Get medical help immediately if the person:

Common causes of head injury include traffic accidents, falls, physical assault, and accidents at home, work, outdoors, or while playing sports. Symptoms The symptoms of a head injury can occur immediately or develop slowly over several hours or days. Even if the skull is not fractured, the brain can bang against the inside of the skull and be bruised. The head may look fine, but complications could result from bleeding or swelling inside the skull. In any serious head trauma, always assume the spinal cord is also injured. Some head injuries result in prolonged or nonreversible brain damage. This can occur as a result of bleeding inside the brain or forces that damage the brain directly. More serious head injuries may cause the following symptoms: Changes in, or unequal size of pupils Chronic or severe headaches Coma

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Becomes unusually drowsy Behaves abnormally Develops a severe headache or stiff neck Loses consciousness, even briefly Vomits more than once

For a moderate to severe head injury, take the following steps: 1. 2. Call 911. Check the person's airway, breathing, and circulation. If necessary, begin rescue breathing and CPR. If the person's breathing and heart rate are normal but the person is unconscious, treat as if there is a spinal injury. Stabilize the head and neck by placing your hands on both sides of the person's head, keeping the head in line with the spine and preventing movement. Wait for medical help. Stop any bleeding by firmly pressing a clean cloth on the wound. If the injury is serious, be careful not to move the person's head. If blood soaks

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When to Contact a Medical Professional Call 911 if:

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There is severe head or facial bleeding The person is confused, drowsy, lethargic, or unconscious The person stops breathing You suspect a serious head or neck injury, or the person develops any signs or symptoms of a serious head injury

Prevention

Basilar skull fractures occur because of blunt trauma and describe a break in the bones at the base of the skull. These are often associated with bleeding around the eyes (raccoon eyes) or behind the ears (Battle's sign). The fracture line may extend into the sinuses of the face and allow bacteria from the nose and mouth to come into contact with the brain, causing a potential infection. In infants and young children, whose skull bones have not yet fused together, a skull fracture may cause a diastasis fracture, in which the bone junctions (called suture lines) widen. Fractures can be linear (literally a line in the bone) or stellate (a starburst like pattern) and the pattern of the break is associated with the type of force applied to the skull. Penetrating skull fractures describe injuries caused by an object entering the brain. This includes gunshot and stab wounds, and impaled objects to the head. A depressed skull fracture occurs when a piece of skull is pushed toward the inside of the skull (think of pressing in on a ping pong ball). Depending upon circumstances, surgery may be required to elevate the depressed fragment. It is important to know whether the fracture is open or closed (this describes the condition of the skin overlying the broken bone). An open fracture occurs when the skin is torn or lacerated over the fracture site. This increases the risk of infection, especially with a depressed skull fracture in which brain tissue is exposed. In a closed fracture, the skin is not damaged and continues to protect the underlying fracture from contamination from the outside world.

used based upon where the blood is located.

Bleeding in the skull may or may not be associated with a skull fracture. An intact skull is no guarantee that there is not underlying bleeding, or hemorrhage, in the brain or its surrounding spaces. For that reason, plain X-rays of the skull are not routinely performed. Epidural, subdural, and subarachnoid bleeding are terms that describe bleeding in the spaces between the meninges, the fibrous layered coverings of the brain. Sometimes, the terms hemorrhage (bleeding) and hematoma (blood clot) are interchanged. Because the skull is a solid box, any blood that accumulates within the skull can increase the pressure within it and compress the brain. Moreover, blood is irritating and can cause edema or swelling as excess fluid leaks from the surrounding blood vessels. This is no different than the swelling that can occur surrounding a bruise on an arm or leg. The only difference is that there is no room within the skull to accommodate that swelling.

Always use safety equipment during activities that could result in head injury. These include seat belts, bicycle or motorcycle helmets, and hard hats. Obey traffic signals when riding a bicycle. Be predictable so that other drivers will be able to determine your course. Be visible. Do NOT ride a bicycle at night unless you wear bright, reflective clothing and have proper headlamps and flashers. Use age-appropriate car seats or boosters for babies and young children. Make sure that children have a safe area in which to play. Supervise children of any age. Do NOT drink and drive, and do NOT allow yourself to be driven by someone whom you know or suspect has been drinking alcohol or is otherwise impaired.

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Subdural Hematoma When force is applied to the head, bridging veins that cross through the subdural space (sub=beneath +dura= one of the meninges that line the brain) can tear and bleed. The resultant blood clot increases pressure on the brain tissue. Subdural hematomas can occur at the site of trauma, or may occur on the opposite side of the injury (contracoup: contra=opposite + coup=hit) when the brain accelerates toward the opposite side of the skull and crushes or bounces against the opposite side. Chronic subdural hematoma may occur in patients who have had atrophy (shrinkage) of their brain tissue. These include the elderly and chronic alcoholics. The subdural space increases and the bridging veins get stretched as they cross a much wider distance. Minor or unnoticed injuries can lead to some bleeding, but because there is enough space in the skull to accommodate the blood,

Skull Fracture The skull is made up of many bones that form a solid container for the brain. The face is the front part of the head and also helps protect the brain from injury. Depending upon the location of the fracture, there may or may not be a relationship between a fractured skull and underlying brain injury. Of note, a fracture, break, and crack all mean the same thing, that the integrity of the bone has been compromised. One term does not presume a more severe injury than the others. Fractures of the skull are described based on their location, the appearance of the fracture, and whether the bone has been pushed in. Location is important because some skull bones are thinner and more fragile than others. For example, the temporal bone above the ear is relatively thin and can be more easily broken than the occipital bone at the back of the skull. The middle meningeal artery is located in a groove within the temporal bone. It is susceptible to damage and bleeding if the fracture crosses that groove.

Intracranial Bleeding Intracranial (intra=within + cranium=skull) describes any bleeding within the skull. Intracerebral bleeding describes bleeding within the brain itself. More specific descriptions are

there may be minimal initial symptoms. Asymptomatic (producing no symptoms) chronic subdural hematomas may be left to resolve on their own; however, it may require attention if the individual's mental status changes or further bleeding occurs.

Depending upon the neurologic status of the affected individual, surgery may be required.

can develop severe headache, nausea, vomiting, and a stiff neck because the blood causes significant irritation to this meningeal layer. It is the same response that can be seen in patients who have a leaking cerebral aneurysm or meningitis. Treatment is often observation and controlling the symptoms. Intraparenchymal Hemorrhage/Intracerebral Hemorrhage/Cerebral Contusion These terms describe bleeding within the brain tissue itself and can be considered a bruise to the brain tissue. Aside from the direct damage to the brain tissue that was injured, swelling or edema is the major complication of an intracerebral bleed. Surgery is not often considered except in situations in which the pressure within the skull increases to the point at which part of the bone is temporarily removed to allow the brain to expand. When and if the brain swelling resolves, another operation replaces the piece of skull that was removed.

Acute head injury result from a trauma to the head leading to brain injury or bleeding within the brain, It's can make edema and hypoxia. Head injury cases is the leading cause of death in the first four decades of life. A head injury also called Traumatic Brain Injury (TBI) is classified by brain injury type; fracture, hemorrhage (epidural, subdural, intracerebral or subarachnoid) and trauma. The management or nursing care plan (NCP) for patient with an acute head injury are divided on the several levels including prevention, pre-hospital care, immediate hospital care, acute hospital care, and rehabilitation. In order to give accurate nursing care plan to the patients, The nurses should understand the principles behind medical treatments. It focuses on the evidence based practice that nurses use in assessing, intervening and managing a severe head injury. A. Assessment Findings on Acute Head Injury Possible causes of acute head injury are assault, automobile accident, blunt trauma, fall and penetrating trauma. The medical team should be perform serious and critical care to handle this cases, So that they can finding correct assessment may happened to the patients such as:

Epidural Hematoma

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Thee dura is one of the meninges or lining membranes that covers the brain. It attaches at the suture lines where the bones come together. If the head trauma is epidural (epi=outside +dura) the blood is trapped in a small area and cause a hematoma or blood clot to form. Pressure can increase quickly within the epidural space, pushing the clot up against the brain and causing significant damage. While individuals who sustain small epidural hematomas may be observed, most require surgery. Patients have improved survival and brain function recovery if the operation to remove the hematoma and relieve pressure on the brain occurs before they have lost consciousness and become comatose. An epidural hematoma may often occur with trauma to the temporal bone located on the side of the head above the ear. Aside from the fact that the temporal bone is thinner than the other skull bones (frontal, parietal, occipital), it is also the location of the middle meningeal artery that runs just beneath the bone. Fracture of the temporal bone is associated with tearing of this artery and may lead to an epidural hematoma.

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Disorientation to time, place or person Unequal pupil size, loss of pupillary reaction Decreased LOC Paresthesia Otorrhea, rhinorea, frequent swallowing.

Diffuse Axonal Injury or Shear Injury A potentially devastating brain injury occurs when the brain injury occurs to the axons, the part of the neurons or brain cell that allows those cells to send messages to each other. Because of the damage of electrical flow between cells, the affected individual often appears comatose with no evidence of bleeding within the brain. The mechanism of injury is usually accelerationdeceleration, and the nerve endings that connect the brain cells rip apart. Treatment is supportive, meaning that there is no surgery or other treatment presently available. The patient's basic needs are met hoping that the brain will recover on its own. Most don't.

To quickly asses a patient's level of consciousness and to uncover baseline change, use the Glasgow Coma Scale. If the patient has already applied with an endotracheal tube and can't response verbally, use the abbreviation "T" score.

B. Diagnostic Evaluation for Acute Head Injury The doctors are who responsible to the patient in the emergency department, they will order some examination trough CT scan or MRI (possible for hemorrhage, cerebral edema, or shift of midline structure), EEG (may reveal seizure activity), ICP monitoring (possible increased of ICP) and skull X-ray (may be fracture).

Subarachnoid Hemorrhage In a subarachnoid hemorrhage, blood accumulates in the space beneath the inner arachnoid layer of the meninges. The injury is often associated with an intracerebral bleed (see below). This is also the space where cerebral spinal fluid (CSF) flows and affected individuals

C. Nursing Diagnose in Acute Head Injury

Nursing Care Plan For Acute Head Injury

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Ineffective tissue perfusion (cerebral) Risk for Injury

Decreased intracranial adaptive capacity.

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The patient will have improved cerebral perfusion The patient will have decreased ICP The patient will have remain free from injury.

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D. Treatment of Acute Head Injury Cervical collar (until neck injury is ruled out) Craniotomy; surgical incision into te cranium (may be necessary to evacuate a hematoma or evacuate contents to make room for swelling to prevent herniation) Oxygen (O2) Therapy; intubation and mechanical ventilation (to provide controlled hyperventilation to decrease elevate ICP) Restricted oral intake for 24 to 48 hours Ventriculostomy; insertion of a drain into the ventricles (to drain CSF in the presence of hydrocephalus, which may occur as a result of head injury; can also be used to monitor ICP).

Provide eye, skin, and mouth care to prevent tissue damage Turn the patient every 2 hours or maintain in a rotating bed if condition allows to prevent skin breakdown.

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G. Implementation of Nursing Care Plan Procedure 1. Assest neurologic and respiratory status to monitor for sign of increased ICP and respiratory distress Monitor and record vital sign and intake and output, hemodynamic variables, ICP, cerebral perfusion pressure, specific gravity, laboratory studies, and pulse oximetry to detect early sign of compromise. Observe for sign of increasing ICP to avoid treatment delay and prevent neurologic compromise Assess for CSF leak as evidenced by otorhea or rinorrhea. CSF leak could leave the patient at risk for infection Assess for pain. Pain may cause anxiety and increase ICP Check cough and gag reflex to prevent aspiration Check for sign of diabetes insipidus (low urine specific gravity, high urine output) to maintain hydration Administer I.V fluids to maintain hydration Administer Oxygen to maintain position and patency of endotracheal tube if present, to maintain airway and hyperventilate the patient and to lower ICP Provide suctioning; if patient is able, assist with turning, coughing, and deep breating to prevent pooling of secretions Maintain postion, patency and low suction of NGT to prevent vomiting Maintain seizure precautions to maintain patient safety Administer medication as prescription to decrease ICP and pain Allow a rest period between nursing activities to avoid increase in ICP Encourage the patient to express feeling about changes in body image ot allay anxiety Provide appropriate sensory input and stimuli with frequent reorientation to foster awarness of the environtment Provide means of communication, such as a communcation board to prevent anxiety

H. Evaluation of Goals in the Nursing Care Plan

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The patient has improved LOC The patient hasdoest not exhibit signs of increased ICP The patient hasremains free from injury Acuet pain r/t decreased cerebral blood flow secondary to physical trauma Outcomes: become relieve of sign & symptoms of pain Provide comfort measures such as positioning in a comfortable position. R: to allow no pharmacological pain relief and promote good circulation to the brain and decrease vasoconstriction Provide calm and quiet environment. R: decrease environmental factors

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5. E. Drug Therapy Options for Head Injury Cases 6. 7.

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Analgesic; codein phosphate Anesthetic; Lidocin (Xylocaine) Anticonvulsant; Phenytoin (Dilantin) Barbiturate; pentobarbital (Nembutal), if unable to control ICP with diuresis Diuretic; mannitol (Osmitrol), furosemide (Lasic) to combat cerebral edema Dopamine (Intropin) to maintain cerebral perfusion pressure above 50 mmHg (if blood pressure is low and ICP is elevated) Glucocorticoid; dexamethasone (Decadron) to reduce cerebral edema Histamin-2 (H2) receptor antagonist such as cimetidine (tagamet), ranitidine (Zantag), famotidine (Pepcid), nizatidine (Axid) Mucosal barriel fortifier; sucralfate (Carafate) Posterior pituitary : vasopressin (Pitressin) if client develops diabetes insipidus. 8. 9.

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17. F. Planing and Goal on Nursing Care Plan

Maintain a patent airway. Assist with endotracheal intubation or tracheotomy as necessary. Administer medications as ordered. Protect the patient for further injury by using side rails. Assist the unsteady patient with walking. Insert an indwelling urinary catheter if ordered. If the patient is unconscious, insert a nasogastric tube to prevent aspiration. Monitor the patients intake and output as needed to help maintain a normovolemic state. Monitor vital signs continuously and check for additional injuries. Observe the patient for headache, dizziness, irritability, and anxiety. Monitor fluid and electrolyte levels and replace them as necessary. Carefully observe the patient for CSF leakage. Tell the patient to return to the hospital immediately if he experiences a persistent worsening headache, forceful or constant vomiting, blurred vision, any change in personality, abnormal eye movements, and twitching.

Nursing Diagnosis for Brain Injury Ineffective airway clearance and impaired gas exchange related to brain injury Ineffective cerebral tissue perfusion related to increased ICP, decreased CPP, and possible seizures Deficient fluid volume related to decreased LOC and hormonal dysfunction Imbalanced nutrition, less than body requirements, related to increased metabolic demands, fluid restriction, and inadequate intake Risk for injury (self-directed and directed at others) related to seizures, disorientation, restlessness, or brain damage Risk for imbalanced body temperature related to damaged temperature-regulating mechanisms in the brain Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, immobility, or restlessness Disturbed thought processes (deficits in intellectual function, communication, memory, information processing) related to brain injury Disturbed sleep pattern related to brain injury and frequent neurologic checks.

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